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  • Audit Icu2

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    AMAL
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    This audit sheet is used to review 5 patients' health records on a given ward/area. It contains questions to check if documentation is up to date, appropriate risk assessments have been completed (e.g. for falls, moving and handling), care plans are in place and followed (e.g. repositioning charts, MUST nutrition assessments), prescriptions are correct, and documentation is clearly written and in proper order. The clinical lead completing the audit would check "yes," "no," or "n/a" for each item for each patient and note any overall observations on the back of the sheet.

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    Audit icu2

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    This audit sheet is used to review 5 patients' health records on a given ward/area. It contains questions to check if documentation is up to date, appropriate risk assessments have been completed (e.g. for falls, moving and handling), care plans are in place and followed (e.g. repositioning charts, MUST nutrition assessments), prescriptions are correct, and documentation is clearly written and in proper order. The clinical lead completing the audit would check "yes," "no," or "n/a" for each item for each patient and note any overall observations on the back of the sheet.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    9 views3 pages

    Audit Icu2

    Uploaded by

    AMAL
    This audit sheet is used to review 5 patients' health records on a given ward/area. It contains questions to check if documentation is up to date, appropriate risk assessments have been completed (e.g. for falls, moving and handling), care plans are in place and followed (e.g. repositioning charts, MUST nutrition assessments), prescriptions are correct, and documentation is clearly written and in proper order. The clinical lead completing the audit would check "yes," "no," or "n/a" for each item for each patient and note any overall observations on the back of the sheet.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 3

    Audit Sheet 2 – Clinical Lead

    Ward/Area Inspected……..………………………….. Date…………………………….

    Review five patient’s health records

    Are services safe/effective/ responsive?


    Questions Comments/observations
    1. Are the patient’s Yes Yes Yes Yes Yes
    records/documentation up No No No No No
    to date? n/a n/a n/a n/a n/a
    2. If the patient is over 65, Yes Yes Yes Yes Yes
    has a falls risk assessment No No No No No
    been completed & n/a n/a n/a n/a n/a
    appropriate action taken?
    3. Has a moving and handling Yes Yes Yes Yes Yes
    assessment been correctly No No No No No
    completed? n/a n/a n/a n/a n/a

    4. Has a PUP (Part 1) Yes Yes Yes Yes Yes


    assessment been No No No No No
    completed? n/a n/a n/a n/a n/a
    If PUP assessment indicates
    further action required go to qu
    5
    5. Has a re-positioning chart Yes Yes Yes Yes Yes
    been commenced and No No No No No
    completed regularly? n/a n/a n/a n/a n/a

    6. Are the observations Yes Yes Yes Yes Yes


    charts completed correctly No No No No No
    and regularly and followed n/a n/a n/a n/a n/a
    up with appropriate
    escalation?
    7. Has a VTE assessment Yes Yes Yes Yes Yes
    been completed correctly No No No No No
    and in a timely manner? n/a n/a n/a n/a n/a
    8. If the patient lacks capacity Yes Yes Yes Yes Yes
    or is a child is there No No No No No
    documentation to support n/a n/a n/a n/a n/a
    communication and
    involvement of NOK/
    parents?

    9. Surgical patient/areas Yes Yes Yes Yes Yes


    Is the consent form for No No No No No
    surgery completed & n/a n/a n/a n/a n/a
    legible with all risks and
    benefits of procedure
    clearly documented?
    1. Has a MUST Yes Yes Yes Yes Yes
    assessment for the No No No No No
    patient been n/a n/a n/a n/a n/a
    1
    V2_Oct.2013
    Audit Sheet 2 – Clinical Lead

    completed fully and in


    a timely way?
    If MUST score indicated further
    action required go to question
    2
    2. Is the MUST Yes Yes Yes Yes Yes
    assessment completed No No No No No
    correctly? n/a n/a n/a n/a n/a
    If MUST score indicated further
    action required go to question
    3&4
    3. If applicable, have
    subsequent care
    plans/charts been
    completed and
    updated in a timely Yes Yes Yes Yes Yes
    way? No No No No No
     Food chart n/a n/a n/a n/a n/a
    Yes Yes Yes Yes Yes
     Fluid chart No No No No No
    n/a n/a n/a n/a n/a
     Weight chart Yes Yes Yes Yes Yes
    No No No No No
    n/a n/a n/a n/a n/a
    4. If applicable, have the Yes Yes Yes Yes Yes
    appropriate referrals No No No No No
    been carried out? n/a n/a n/a n/a n/a

    1. Are the prescription Yes Yes Yes Yes Yes


    charts legible, in date No No No No No
    and signed by the n/a n/a n/a n/a n/a
    person prescribing?
    2. Are any medications Yes Yes Yes Yes Yes
    given or omitted No No No No No
    recorded in the chart in n/a n/a n/a n/a n/a
    line with policy?
    1. Is the documentation in Yes Yes Yes Yes Yes
    the correct order with No No No No No
    no loose sheets? n/a n/a n/a n/a n/a

    2. Is the documentation Yes Yes Yes Yes Yes


    legible with clear No No No No No
    signatures? n/a n/a n/a n/a n/a
    Enter general overall observations comments here & continue on reverse if required

    2
    V2_Oct.2013
    Audit Sheet 2 – Clinical Lead

    3
    V2_Oct.2013

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