Section A – Mandatory Indicators
The following questions relate to mandatory requirements, countersignature, content and errors
All entries to the record:
*Person refers to child/young person/adult / Y / N1 / are dated
2 / are timed (24 hour clock)
3 / are signed in full (no initials)
4 / are designation at 1st entry
5 / are written in black ink
6 / has a unique patient Health and Social Care number is on each single page
7 / has legible hand writing
8 / arerecorded in real time/chronological order
9 / made by a nursing student/s are countersigned by a registered nurse
(if N/A click yes)
10 / made by a health care support worker comply with local countersignature policies.
(if N/A click yes)
11 / are free from jargon, meaningless phrases or text-style language
12 / are free from speculative or opinion based statements
13 / That have errors, are dated
(if N/A click yes)
14 / That have errors, are timed (24 hour clock)
(if N/A click yes)
15 / That have errors, signed in full (no initials)
(if N/A click yes)
16 / That have errors, are attributable
(if N/A click yes)
17 / That have errors, are crossed out with a single line
(if N/A click yes)
Patient/Client ID number
Date audit completed
Questionnaire ID
Date data put on system
Section B: AssessmentIndicators
The following questions relate to initial assessment and risk assessments.
In the initial assessment recording of the following is evident:
Y / N1 / full name
2 / date of Birth
3 / home address
4 / contact telephone number
5 / General Practitioner
6 / assessing Nurse
7 / reason for assessment or referral
8 / time of assessment or referral
9 / date of assessment or referral
10 / next of kin/contact
11 / parental responsibility(if N/A click yes)
12 / first language/communication needs
13 / religious Beliefs
14 / ethnic group
15 / relevant Items of Property
16 / external aids
17 / past medical history
18 / Social History
19 / allergy status
20 / height/length
21 / weight
22 / blood pressure
23 / pulse
24 / respiration rate
25 / temperature
26 / Early Warning Score
27 / pain score
28 / physical impairment
Y / N
29 / mental/emotional State
30 / Persons Skin Integrity
31 / Persons Normal Bowel Habit
32 / Persons Normal Urinary Habit
33 / Admission urinalysis
34 / Menstrual History (if N/A click yes)
35 / Pregnancy Test (if N/A click yes)
36 / Sleep Pattern
37 / The person’s/parent’s understanding of why he/she/child/young person is accessing a service
(If answer person unresponsive click yes)
38 / Consent obtained for assessment
39 / Infection Prevention control risk assessment
40 / Nutrition Screening MUST/STAMP
41 / Pressure Ulcer Risk Braden Score/Glamorgan
42 / Moving and Handling risk assessment
43 / Judged Risk of Falling
44 / Bed Rails assessment
Section C: Care PlanningIndicators
The following questions relate to identification of needs, plan of care/treatment/support and outcomes.
*person also refers to parent/person with parental responsibility / Y / N1 / The plan of care records evidence of that all needs of the person have been identified in the initial assessment
2 / The plan of care records that theperson was involved in discussion regarding his/her plan of care(if person unresponsive click yes)
3 / The plan of care records the preference of the person (if person unresponsive click yes)
4 / The plan of care records all the relevant needs identified by the completed risk assessments
5 / The records demonstrate that the religious/cultural needs of the person have been accommodated
6 / The records demonstrate that the frequency of evaluation of planned care/treatment/support has been recorded
7 / The records demonstrate that the plan has been evaluated
8 / The records demonstrate that the plan identifies outcomes for all planned care/ treatment/support
9 / The records demonstrate the persons progress towards all outcomes
10 / The records demonstrate were outcomes are not met the plan is updated to implement new care/ treatment/support
11 / The record is updated when an outcome has been achieved
12 / The record is updated when a new need is identified
13 / Incidents/accidents are recorded
14 / Following an incident/accident, the plan of care is updated to include all relevant interventions/actions
15 / Records demonstrate that ongoing care /treatment/support have been discussed with the person (If person lacks understanding click yes)
16 / The records demonstrate the ongoing planned care/ treatment/support included the preferences of the person ( if person unresponsive click yes)
17 / The records demonstrate ongoing communication with the multi professional team ,in relation to the person’s care
18 / The records demonstrate ongoing communication with relatives/carers, in relation to the person’s care, with their permission
19 / The records demonstrate that there is a record of discussions with the person in relation to obtaining consent for care/treatment/support
Section D: Discharge Planning Indicators
The following questions relate to discharge or transfer planning.
Y / N1 / There is evidence in the records of the expected date/time of discharge/transfer to other care setting
(If answer end of life click yes)
2 / The expected date of discharge has been recorded within 24hours of admission
(Ifanswer end of life click yes)
3 / The expected date of transfer has been recorded
(If answer end of life click yes)
4 / There is evidence in the records of the person being involved in the discussions relative to discharge/transfer planning
(If answer person lacks understanding or person unresponsive or end of life click yes)
5 / There is a record of relatives/carers being involved in discussions relating to discharge/transfer planning(with permission of person)
(If answer end of life click yes)
6 / Where care is required following discharge/transfer, there is a record of discussions with the appropriate community/liaison/specialist nurses.
(If answer end of life click yes)