CONCURRENT NURSING AUDIT

(Venson & Magtalon, 2006)

UNIT: DATE: TIME:
Patients Name:
Diagnosis:
COMMENTS YES NO N/A JUSTIFICATION IMPLICATION
A. FORMAT
1. Nursing history is
complete within 24 hours
2. Attending Physicians
name is recorded
3. Sheets arranged in
proper sequence
4. Informed consent for
admission/ special
procedure and
treatments are signed by
client and/or S.O.
5. Patients full name
recorded on every sheet
6. Charting in correct ink
color per shift utilized
7. No erasures. Errors
drawn through and
identified
8. Correct abbreviations
used
9. Laboratory results
attached according to
dates
B. DOCTORS ORDERS
1. Doctors orders are
legible, dated and signed
2. Medications are
prescribed in generic
3. Orders are carried out
and signed within 1 hour
4. Verbal orders are
countersigned by
physicians 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 procedure/
referrals are
accomplished and noted
within the shift
C. NURSES NOTES
1. Nurses notes are
complete, legible and
relevant
2. Notes are signed with
designation of nurse
stated
3. Assessment
a) Idiosyncrasies to food,
drugs, substance, etc, are
communicated and
documented
b) Religious beliefs/
practices on food,
treatment, drug, or blood
administration noted
c) General physical and
mental condition noted
d) Unusual observations/
critical conditions are
documented
e) Patients problems
identified/ charted
4. A nursing care plan exist
5. Nursing actions are
documented
6. Effectiveness of nursing
actions noted
7. Teaching/ discharge
plans noted and copy
given to patient or
family
TOTAL SCORE
SUMMARY

FORMAT

DOCTORS ORDERS

NURSE NOTES

Conclusion:

Recommendation: