What is a Nursing Audit Checklist and How to Create One

What is a Nursing Audit Checklist and How to Create One

A nursing audit checklist is an important tool for hospitals and medical institutions. It can help ensure that all patient care standards are being met and that nurses are following all necessary procedures. However, if you haven’t used it before, this type of checklist might seem unfamiliar or even daunting.

Don’t worry! Creating a nursing audit checklist is actually quite simple, and we’ll walk you through the process step-by-step. In this article, we will discuss what a nursing audit checklist is, why it’s important, and how to create one. 

 

What is a Nursing Audit?

It is a detailed process of evaluating the quality of nursing care through the systematic review of patient records made by healthcare professionals. It helps healthcare institutes ensure that patients are consistently receiving quality care and allows nurse managers to determine improvements in healthcare opportunities.

 

What is the Purpose of a Nursing Audit?

There are many reasons why hospitals conduct these audits. The purpose of a nursing audit is to:

  • To determine potential risk factors that might lead to an adverse patient outcome
  • To improve the quality of patient care
  • To assess the compliance of hospital staff with institutional policies and procedures
  • To ensure that nurses are following best practices
  • To provide feedback to nurses on their performance

 

A nursing audit is an important tool for quality assurance and can help prevent errors, improve patient safety, and ensure that nurses are providing the best possible care.

 

Methods of Nursing Audits

There are two types of conducting these methods:

 

Concurrent Nursing Audit

This type of audit is conducted while the patient is still in the hospital. It involves reviewing the patient’s medical record and chart to see if there are any discrepancies between what happened and what was documented.

 

Retrospective Nursing Audit

A retrospective nursing audit is conducted after the patient has been discharged from the hospital. It involves going through the patient’s medical records and chart to see if there were any lapses or flaws.

Both types of audits are important, but the concurrent nursing audit is more effective in identifying errors and discrepancies.

 

What is a Nursing Audit Checklist?

A nursing audit checklist is a list of items that need to be reviewed. The checklist helps ensure that every aspect of patient care is being assessed and evaluated.

 

Why is a Nursing Audit Checklist Important?

It is important because it:

  • Helps ensure that all aspects of the patient’s care are being evaluated
  • Helps ensure that all necessary procedures are being followed
  • Helps identify any risk factors that might lead to an adverse patient outcome
  • Helps boost the overall quality of patient care

 

What Should Be Included in a Nursing Audit Checklist?

This checklist should include:

  • The full name of the inspector conducting the audit
  • The date of the audit
  • The name of the patient being audited
  • The medical record number of the patient being audited
  • The type of nursing audit being conducted (concurrent or retrospective)
  • A list of all items that need to be reviewed during the audit
  • Any discrepancies or errors found during the audit
  • The name of the person who will be reviewing the findings of the audit

 

How to Create a Nursing Audit Checklist

Creating a nursing audit checklist is simple. Just follow these steps:

 

Step 1: Create an Audit Team

The first step is to create an audit team. The audit team should be composed of a nurse manager, a quality assurance coordinator, and a staff nurse.

 

Step 2: Choose the Type of Audit

The next step is to choose the type of audit that you want to conduct. As mentioned earlier, there are two types of audits, which are concurrent audit and retrospective audit.

 

Step 3: Select the Patients

The next step is to select the patients who will be audited. To do this, you can use a random number generator or a patient selection tool.

 

Step 4: Create the Checklist

Once you have selected the patients, you can create the checklist. The checklist should include all of the items that need to be reviewed during the audit. Some important items that you should include are the following:

  • The patient’s medical record
  • The patient’s chart
  • The nursing progress notes
  • The physician orders
  • The nurse’s documentation
  • The medication administration records
  • The laboratory results
  • The radiology reports

 

Step 5: Conduct the Audit

The next step is to conduct the audit. To do this, you will need to review the medical records and charts of the patients who have been selected for the audit.

 

Step 6: Review the Findings

After you have conducted the audit, you will need to review the findings. This step is important because it will help you identify any errors.

 

Step 7: Implement Changes

If you find any discrepancies, you will need to implement changes. This step is important because it will help improve patient care quality.

 

Create a Nursing Audit Checklist with DATAMYTE

If you want to maximize the potential of a nursing audit, then you should consider using digital checklists. With DATAMYTE and its Digital Clipboard, you are able to create a comprehensive digital nursing audit checklist that has all the bells and whistles. DATAMYTE’s Digital Clipboard comes with a number of features that are designed to make nursing audits more efficient and effective, such as:

  • The ability to create an audit trail
  • The ability to track changes
  • The ability to generate reports
  • The ability to share information with other members of the audit team

 

If you want to learn more about how DATAMYTE can help you with nursing audits, then please contact us today. We would be more than happy to discuss our products and services with you. 

 

Conclusion

With a nursing audit checklist, you can help improve the quality of patient care and identify any errors or discrepancies. Creating a checklist is simple and can be done with DATAMYTE’s Digital Clipboard. Get started today!

 

 

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