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Nursing Documentation Monthly Audit Checklist
Section 1: General Documentation Standards
1. All entries are legible and written in permanent ink or entered electronically
Yes
No
2. Entries are dated and timed accurately
Yes
No
3. Each entry includes the full name and designation of the person documenting
Yes
No
4. No blank lines between entries
Yes
No
5. Corrections made according to facility policy (e.g., single line through error, initialed, dated)
Yes
No
6. No unauthorized abbreviations used
Yes
No
7. Documentation is completed in real-time or as soon as possible after care is given
Yes
No
Section 2: Assessment and Care Planning
1. Initial assessments completed within the required time frame
Yes
No
2. Ongoing assessments documented regularly (e.g., daily, shift-wise, PRN)
Yes
No
3. Pain assessments and re-assessments documented
Yes
No
4. Nutritional, skin integrity, and fall risk assessments present and updated
Yes
No
5. Care plans are individualized and updated based on resident/client needs
Yes
No
6. SMART goals (Specific, Measurable, Achievable, Relevant, Timely) are documented in care plans
Yes
No
7. Multidisciplinary input reflected in care planning
Yes
No
Section 3: Medication Administration Records (MAR)
1. MARs are up to date and match physician orders
Yes
No
2. PRN medications include reason for administration and outcome/effectiveness
Yes
No
3. All medication refusals, omissions, or errors are documented and followed up
Yes
No
4. Controlled drug administration is accurately documented and double-signed
Yes
No
5. Allergies and adverse reactions clearly recorded
Yes
No
Section 4: Progress Notes / Shift Reports
1. Notes reflect the resident’s/client’s condition, interventions, and outcomes
Yes
No
2. Any changes in condition are documented and escalated appropriately
Yes
No
3. Communication with family or caregivers is noted when applicable
Yes
No
4. Interdisciplinary communication is recorded (e.g., physician updates, therapy notes)
Yes
No
5. Resident/resident behavior and responses to interventions are clearly noted
Yes
No
Section 5: Incident and Event Reporting
1. Falls, injuries, medication errors, or behavioral incidents are fully documented
Yes
No
2. Timely completion of incident reports
Yes
No
3. Follow-up assessments and interventions are documented
Yes
No
4. Evidence of corrective actions taken
Yes
No
5. Family or guardian notifications are recorded
Yes
No
Section 6: Wound and Skin Documentation
1. Wound assessments are complete with size, stage, and description
Yes
No
2. Wound care provided matches physician or wound nurse orders
Yes
No
3. Photographic documentation included when policy requires
Yes
No
4. Healing progress or deterioration is clearly documented
Yes
No
Section 7: Consent Forms and Legal Documents
1. Signed consent for care, medications, and procedures on file
Yes
No
2. Advanced directives and DNR orders documented and accessible
Yes
No
3. Guardianship or POA documents on file and current
Yes
No
Section 8: Compliance with Policies and Procedures
1. Documentation aligns with facility and regulatory policies (e.g., CMS, Joint Commission)
Yes
No
2. HIPAA compliance is maintained in all documentation
Yes
No
3. Evidence of training or reminders provided for staff with repeated documentation issues
Yes
No
Section 9: Audit Summary and Follow-Up
1. Areas of non-compliance identified
Yes
No
2. Staff notified of documentation deficiencies
Yes
No
3. Remedial actions assigned and deadlines set
Yes
No
4. Re-audit or follow-up review date scheduled
Yes
No
Section 10: Notes
1. Audit Date
2. Auditor Name
3. Unit/Facility
4. Total Charts Reviewed
5. Charts with 100% Compliance