MEDICAL RECORD AUDIT TOOL

OPEN Nursing Review for Inpatient Adult and Pediatric Units

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REVIEW WITH MANAGER by the 5th of the month and FAX completed form to by the 10th of the month:
April Bowles at 982-6838 or MAIL to Box 800476.
Please audit the complete paper medical record

9CHECK THE APPROPRIATE BOX, EITHER: 9Y = Yes 9N = No 9NA = Not Applicable

Unit:

Manager Name:
CHART 1

CHART 2

Date Manager Reviewed:

CHART 3
CHART 4

Medical Record Number:

Admit Date:
Audit Date:
Reviewer(s):
Print Name

1. BLUE CHART

CHART:

Y N NA Y N NA Y N NA Y N NA
1.01 Patients name, sex, address, date of birth, admission diagnosis and
authorized representative or emergency contact are available in the record
(face sheet, EMR, database)?
1.02 If the patient is on Isolation, is there an information sheet from Infection Control in a page
protector? (NA if not on Isolation)
If the patient had a procedure(s) are the following in the chart? Check NA if no procedures
identified.
(Preprocedure checklist, Bedside form #050475, OR/Procedure #33033)
1.03 Was the Preprocedure verification section completed?
1.04 Was the Side/Body Site Verification section completed? (N/A if site verification not needed)
1.05 Is there an informed consent form? (NA if consent form not needed)

2. INFORMED CONSENT (LIP)

CHART:

Y N NA Y N NA Y N NA Y N NA

If Informed Consent was needed, consent form includes each of the following: (NA if no consent needed)
2.01 The nature of the proposed care, treatment, services, medications, interventions or procedures.
2.02 The potential benefits, risks, or side effects, including potential problems that might occur
during recuperation.
2.03 Reasonable alternatives as well as the relevant risks, benefits and side effects related to
alternatives, including the possible results of not receiving care, treatment and services.
2.04 Anesthesia type is accurately documented.
2.05 Was Informed Consent signed by patient or appropriate legal surrogate?
2.06 If applicable, blood consent obtained and includes the potential benefits, risks, side effects and
potential problems that might occur and is signed by patient or surrogate? (NA if no blood consent)

3. ADMITTING HISTORY AND PHYSICAL (LIP)

CHART:

Y N
3.01 Was an H&P completed within 30 days before or 24 hours after admission and placed in the
patients medical record within 24 hours after admission or registration but before surgery?
3.02 If H&P is less than 30 days, was updated examination completed and documented in the patients
medical record within 24 hours of admission or registration but before surgery?
Does the H&P include each of the following:
3.03 Chief complaint
3.04 Relevant past medical history
3.05 Details of present illness/injury
3.06 Social history
3.07 Allergies
3.08 Complete medication list including name, dose, route and frequency
3.09 Family history
3.10 Physical examination pertinent to diagnosis (including normal and abnormal findings
pertinent to care)
3.11 Planned course of action

2
Y N

3
Y N

4
Y N

To see related Joint Commission Standards see the Joint Commission Hospital Manual located as a computer desktop icon.
FORM 090801

NOT A CHART DOCUMENT

(REV 8/24/10)

To reorder, log onto http://www.virginia.edu/uvaprint/HSC/hs_forms.pl

MEDICAL RECORD AUDIT TOOL

4. INITIAL SCREENING (DATABASE)

CHART:

4.01 If Database blank, was at least 1 attempt made to obtain information if patient/family
unable to provide on admission? (NA if database is completed)
Note the Unit patient admitted to (information for Unit Manager)
4.02 Was initial screening by the RN initiated within 8 hours of admission to hospital and
completed within 24 hours? NOTE: IF Critical Care or L&D screening must be Initiated
AND completed within 8 hours.
4.03 If applicable, was person identified by patient notified of hospital admit? (NA if pt answers no)

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1

Y N NA Y N NA Y N NA Y N NA

4.04 For patient 18 years or older and patient able to answerIs there an answer marked to the
question, Do you have an Advance Directive? (NA if less than 18 years old)
4.05 If the patient has a resuscitative (code) status order in MIS is there a copy in the Red Page
Protector? (NA if patient is full code)
Were the following Initial screenings completed?
4.06 Learning (including barriers)
4.07 Pain
4.08 Function/Safety
4.09 Nutrition/Integumentary
4.10 Psychosocial (including abuse, neglect)
4.11 Discharge Factors and Family Strengths

5. NURSING ASSESSMENT (May be printout of electronic documentation)

Each section should show WDL, exceptions or score. Should be no NAs.
(Systems Assessment on admission and every 12 hours)
CHART:
Note the number of total number of assessments in the chart in this box.
5.01 Pain
5.02 CAM Screening complete
5.03 Neurological
5.04 Respiratory
5.05 Cardiovascular/PVS
5.06 Abdominal
5.07 Integumentary including location of lines, drains, tubes, wounds, pressure ulcers
5.08 Musculoskeletal/Mobility
5.09 Psychosocial including suicide assessment
5.10 Genitourinary
5.11 Braden Scale (completed with each assessment)
5.12 Fall Risk completed
5.13 Safety needs addressed, as appropriate

6. HAND-OFF OF CARE (HOC)

CHART:

1
Y N

2
Y N

3
Y N

4
Y N

Y N NA Y N NA Y N NA Y N NA

If patient transferred, documentation of hand-off includes: (NA if no transfer)

Note number of hand-off reports (last page with signatures) in chart (in progress notes)
6.01 Did the sending unit complete and sign the report and/or provide hand-off documentation on
the flow sheet?
6.02 Did the receiving unit complete and sign the report and/or provide hand-off documentation
on flow sheet?
6.03 If the patient returns to the sending unit (as from a test/procedure) is the hand-off report
completed by the receiving nurse and/or documentation on the flow sheet?

7. FLOWSHEET

(May be a print-out of electronic documentation)

CHART:

Note the total number of flowsheets in the chart.

For each flowsheet there should be documentation as below.
7.01 Was implementation of comfort plan initiated within 1 hour after pain identified and
assessed? (NA if no pain)
7.02 Pain Intervention was documented within 1 hour of pain score unacceptable to pt
(N/A if no pain or pain within pts comfort goal)
7.03 Were there clinical triggers noted that would indicate activation of the MET, PERT or NERT
team? (N/A if no clinical indication for a team)
7.04 Was the team activated? (See MET/PERT/NERT flowsheet) (N/A if no triggers)

Y N NA Y N NA Y N NA Y N NA

MEDICAL RECORD AUDIT TOOL

8. DAILY CARE PLAN

CHART:

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1

Note the total number of Care Plans

Y N NA Y N NA Y N NA Y N NA

8.01 Are general goals initiated or continued daily? Patient admitted to hospital
8.02 Are general goals initiated or continued daily? Patient admitted to hospital
8.03 If unique needs are identified, are corresponding interventions noted?
(NA if no unique needs)
8.04 If unique needs are identified, are corresponding interventions noted?
(NA if no unique needs)

9. PATIENT AND FAMILY EDUCATION

Nights
Days
Nights
Days

CHART:

Y N NA Y N NA Y N NA Y N NA

Patient/family/significant other are provided education specific to their needs, condition and care?
Note total number of education sessions.
When education was provided, did each session include each of the following?
9.01 Teaching is amended to address any learning barriersNoted in Comments.
(NA if no barriers.)
9.02 Learner
9.03 Method
9.04 Response
Documentation of topic taught during admission. Check any topics taught during admission:
9.05 General
9.06 Diagnosis/Illness/Injury
9.07 Before/after surgery/procedures/treatment
9.08 Safety
9.09 Activity/mobility
9.10 Self-care/ADLs
9.11 Pain management
9.12 Medications
9.13 Equipment/supplies
9.14 Diet/nutrition
9.15 Coping
9.16 Infection prevention and control
9.17 Wounds/lines/drains/airways
9.18 Discharge/followup

10. INTERDISCIPLINARY PATIENT CARE

PLANNING ROUNDS (Interdisciplinary Plan of Care,

CHART:

Social Work D/C Note, PTP, Therapy Notes/Discharge Plan)

10.01 Is there evidence of an individualized plan of care, treatment and services based on screening/

1
Y N

2
Y N

3
Y N

4
Y N

assessment that provides the opportunity to involve patients and families as appropriate?PS Goal 13
10.02 Was interdisciplinary discharge planning started within 48 hours of admission?
10.03 Coordination is noted among disciplines providing care, treatment, teaching and services.

11. OVERALL DOCUMENTATION All patient medical record entries must

be legible, complete, and authenticated (in written or electronic form) by the responsible
person, consistent with hospital policies and procedures. All documentation must have
CHART:
name/signature and/or PIC plus date/time.
11.01 Overall, does documentation meet this standard?
11.02 If there are any abbreviations, are they approved? Do not use U, IU, QD, QOD, MS,
MSO4, or MgS04
If NO is checked, note date/time/providers:

Y N

Y N

Y N

Y N

MEDICAL RECORD AUDIT TOOL

CLOSED CHART Nursing Review within 7 Days of Discharge

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12. DISCHARGE INFORMATION REVIEW FOUR CLOSED (POST-DISCHARGE) CHARTS WITHIN 7 DAYS OF DISCHARGE.
PLEASE AUDIT THE COMPLETE PAPER MEDICAL RECORD

9CHECK THE APPROPRIATE BOX, EITHER: 9Y = Yes 9N = No 9NA = Not Applicable

Unit:
CHART 1

CHART 2

CHART 3

CHART 4

Medical Record Number:

Admit Date:
Audit Date:
Reviewer(s):
(Progress Notes, SW D/C Note, D/C Instructions, Therapy Notes, Home Health Referral, CHART:
1
2
3
4
MD Discharge Summary)
Y N NA Y N NA Y N NA Y N NA
12.01 Was the patient/family given information about discharge including (as applicable):
reason, how to obtain further care, treatment and services to meet his/her needs;
pain management plan?
12.02 If applicable, did the hospital help arrange for services to meet the patients needs after
discharge? (NA if no services needed)
12.03 Was a list of medicines provided to the patient/family?
12.04 Were discharge instructions and other teaching tools given to the patient/family and did the
patient/family demonstrate understanding?
12.05 If patient does not speak English was an interpreter (live or phone) used to provide instructions?
(NA if patient spoke English)
12.06 If applicable, was patient given choice of services/agencies? (NA if no services offered)
If the patient was discharged to a facility or home with home health, clinical information was provided
including: (NA if standard discharge to home)
12.07 Reason for discharge, physical, and psychosocial status.
12.08 A summary of care, treatment, and services provided and progress toward goals.
12.09 Community resources or referrals or other specific needs after discharge

FOR PATIENTS LESS THAN 18 YEARS OLD

13. PEDIATRIC CARE ASSESSMENT ADDENDUM

CHART:

For children (under 18 years)

Does the assessment of infants, children and adolescents include?

13.02 Length/height
13.03 Weight
13.04 Immunization status
13.05 If applicable, newborn care (NA if not newborn)
13.06 Are the specific academic educational needs of the child or youth identified
and implemented?
13.07 Are family/guardian expectations for and involvement in the assessment, initial treatment,
and continuing care of the patient documented?

RELATED MEDICAL CENTER POLICIES

0125 Diagnostic Testing
0129 Hospital Education
0146 Blood Use
0153 Conscious Sedation
0159 Restraints
0197 Suicide Precautions
0213 Abuse & Neglect

Y N NA Y N NA Y N NA Y N NA

13.01 Developmental age

0024 Consent
0025 Discharge Planning
0026 Pt Rights & Responsibilities
0063 Inpatient Transfers
0091 Infection Control & Prevention
0094 Documentation
0097 Bed Assignment

0239 Pain
0259 Medications
0965 Emergency Response
0269 Patient Education
CCS Documentation Guidelines