Nursing Care Plan Audit Checklist

An audit checklist for nursing care plans is an indispensable way of ensuring that nurses meet hospital standards, while helping nurse managers assess healthcare improvements.

To create the nursing care plan audit checklist, a literature review was performed and interviews with 10 experts in clinical nursing and accreditation were held. A statistical analysis was then undertaken to ensure compliance with auditing indicators.

1. Patient Assessment
Assessing a client is the initial step a medical professional must take when deciding the appropriate care for a client. This may involve reviewing symptoms, medical records and diagnostic reports, which may all influence this assessment process which can often be subjective in its approach.

Acquiring the skills needed to accurately evaluate patients takes practice. Working with a medical mentor and taking advantage of simulation training can help.

Successful patient assessments can lead to the creation of a plan of care designed to stabilize and heal patients. Goals set within this care plan must be specific, measurable and attainable for maximum effectiveness.

Nursing audit is the practice of evaluating nursing quality by reviewing clinical records made by healthcare professionals, helping ensure healthcare institutions consistently deliver top-tier patient care while helping nurse managers identify areas for team improvement. A nursing audit checklist is an effective tool for conducting an inspection in this way.

2. Medication Management
The nursing care plan audit checklist establishes the nurse’s role in managing client medication. This involves communicating with them regarding what medications they’re taking, how and why, as well as providing communication regarding these matters to the client.

Medication management also involves verifying all nursing actions have been undertaken successfully. To do this, subjective and objective data such as response to treatments, pain scale responses or vital signs must be examined. Nurses should write the date on which their plan was created and sign it for accountability purposes.

Nurses should use the nursing care plan as a platform to document and evaluate client progress, noting if goals and outcomes were accomplished as planned, as well as any factors which positively or negatively influenced those results. Evaluations should include rationales – scientific explanations linking pathophysiological principles with selected nursing interventions that provide evidence for future planning as well as evaluation of the client’s care.

3. Patient Education
Patient education is an integral component of nursing care. Studies demonstrate that patients involved in their healthcare experience better outcomes; unfortunately, time constraints and a heavy workload prevent many nurses from taking the necessary steps to provide education for their patients.

An effective patient education program involves four components: assessment, planning, implementation and evaluation (APIE). Assessment involves gathering information about daily activities, knowledge, health beliefs and understanding levels so as to tailor education according to individual patients.

Implementation involves selecting educational materials tailored to both patient needs and healthcare providers’ abilities to teach. Effective strategies may include using plain language and emphasizing behaviors rather than knowledge; teaching patients to recite information aloud can also serve to assess comprehension. Evaluation measures whether patients adhere to their plan of care – this factor depends on such things as age, work experience and understanding medical terminology.

4. Patient Safety
Patient safety encompasses measures designed to prevent and minimize errors in healthcare delivery systems, along with verification protocols designed to guarantee accurate information. Such protocols can reduce unnecessary expenses, minimize legal risk and enhance a hospital’s standing within their community.

An audit checklist for nursing care plans should include measures that assess whether medical records in a hospital are up-to-date and accurate, and steps taken to improve communication among staff, patients and their families.

Manage patient safety requires creating an environment of transparency and accountability in all levels of healthcare organizations, from managers and contract workers to frontline staff and managers alike. This requires everyone from managers, contract workers and frontline staff communicating openly about any errors or concerns they witness and that policies and procedures are clearly laid out and enforceable – this helps reduce stress levels as people feel more comfortable reporting observations while also creating an atmosphere where mistakes can be acknowledged without fear of retribution or negative repercussions from them.