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Audit Icu2

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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35 views

Audit Icu2

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.

Uploaded by

AMAL
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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
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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

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V2_Oct.2013
Audit Sheet 2 – Clinical Lead

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V2_Oct.2013

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