PATIENT NAME:______DATE ______
Audit done by______initial______
I. PATIENT HOME CHART
A. Three-ring binder chart with cover sheet of Newborn ______
letterhead with Client name typed on it.
B. Front Cover :
· Allergy Sticker ______
· Falls risk Sticker ______
1. Front and back pockets, insert:
Ø Verbal Order Forms ______
Ø Envelopes ______
2. Chart Dividers with sections labeled on tabs
(In this order if sections are pertinent)
a) Home Emergency Plan ______
q Including backup power source and length of
power supply on Emergency Plan
b) Communication Log (Insert Narrative Notes) ______
c) Physician Order Sheet - POT - check date ensure current ______
d) Allergies listed ______
q Mounting forms for verbal orders ______
e) Abbreviation List ______
f) Instructions for PD Flowsheet ______
g) Clinical Progress Notes ______
h) Medication Profile and MAR
i) MAR match the POT in dosage and concentration form ______
j) Equipment Changing and Cleaning ______
k) Emergency Bag Contents ______
l) Apnea Record ______
m) Seizure log ______
n) Trach/Vent Flowsheets and Instructions ______
o) Inventory Review ______
p) Incident Reports (blank)_
q) Procedure and Policy Sign Off Sheet ______
r) Controlled Substance Log ______
s) New Nurse Orientation Forms ______
C. Is the BLUE binder in place with nurses signatures?
D. :Forms inside Blue Binder
1. Pertinent Policy and Procedures for Client ______
2. Pertinent Caretaker Education Information for:
q Treatments ______
q Equipment ______
q Emergency Procedures ______
q Safety: Fire/Electrical/Oxygen ______
q Medication Storage ______
3. Extra Forms ______
II. CLIENT’S ONGOING FILE (Manila Folder/File in Medical Records)
Ongoing Clinical Progress Notes, PD Flowsheets, and ______
documents that are submitted weekly from the client’s
home chart. (Medical Records to set up)
Deficiency Summary:______
Correction Summary: ______
RN Chart Auditor: ______
DATE: ______INITIAL:______