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Nursing Audit Tool

Appraisal score Overall Score: /5.0

Name: Employee ID:


Job Title: Hire Date:
Department:

Appraisal Date:
Review Period: From: To:
Appraised by:

Directions: Write the appropriate score in the proper column


denoting the extent to which the nurses performed these
functions. Use the following guide.

Definition of Ratings

5-Outstanding (exceptional; consistently exceeds expectations)


4-Exceeds Expectations (consistently meets, and frequently
exceeds expectations)
3-Competent (Conforms to standards, meet expectation)
2-Needs Improvement (does not consistently meet expectations)
1-Unacceptable (Significantly below standard and unsatisfactory)

Hospital Behavioral Expectations Score: /5.0(10%)


Performance Level 5-Outstanding; 4-Exceeds Expectation; 3-Competent;
2-Needs Improvement; 1-Unacceptable
Competency Self Supervisor Average
A. Format
1. Nursing History is completed
within 24 hours.
2. Documented attending
physicians name.
3. Sheets are properly arranged
according to the agreed
sequence.
4. Informed consent for
admission/special procedures
and treatments are signed by
patient and significant others.
5. Patient name are recorded in
every sheet.
6. Utilization of correct ink color in
charting per shift.
7. No erasures. Error drawn
through and
identified/countersign with
initials.
8. Utilization of correct
abbreviations.
9. Laboratory results are properly
arrange according to dates.
B. Doctors Order
1. Doctors orders are legible,
dated and signed.
2. Medication prescriptions are in
generics.
3. Carry out and signed orders
within 1 hour.
4. Verbal orders are countersigned
by physician within 30 minutes.
5. Standing orders are signed
within 1 hour.
6. STAT orders are timed, carried
out, charted and signed within
15-20 minutes.
7. Special procedures/referrals are
accomplished and noted within
shift.
C. Nurses Notes
1. Nurses note are complete,
legible and relevant.
2. Notes are signed with
designation of nurse stated.
3. Complete assessment.

4. Formulate a comprehensive
nursing care plan.
5. Nurse actions/interventions are
documented.
6. Effectiveness of nursing actions
noted.
7. Provide teaching/discharge
plans to patient, family or
significant others.

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Employees Comments

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