A Patient Care Checklist using eAuditor Audits & Inspections helps ensure that healthcare providers deliver consistent, high-quality care. The checklist can be customized to meet specific needs based on the type of care setting (hospital, clinic, long-term care, etc.) and regulatory standards.
Here’s a sample Patient Care Checklist that you can use in eAuditor Audits & Inspections:
1. General Information
Date of Audit
Auditor’s Name
Patient’s Name
Patient ID Number
Room/Bed Number
2. Patient Identification and Safety
Is the patient correctly identified using two identifiers (e.g., name and date of birth)?
Does provider maintain visible allergy alerts?
Is the call bell within reach?
Does provider assess and document patient fall risks?
Is the patient’s room free of hazards?
Are bed rails or restraints used appropriately if needed?
3. Vital Signs Monitoring
Does provider check vital signs as per the care plan?
Temperature
Blood Pressure
Pulse Rate
Respiratory Rate
Oxygen Saturation
Does provider report and address any abnormalities in vital signs promptly?
Is equipment for vital signs (thermometers, BP cuffs) clean and functional?
4. Medication Administration
Is the medication list up-to-date and consistent with the care plan?
Are the 5 rights of medication administration followed (Right Patient, Right Drug, Right Dose, Right Route, Right Time)?
Does provider store medications securely (e.g., in a locked cabinet)?
Does provider maintain clear records of administered medications?
Are PRN (as needed) medications documented and administered appropriately?
Does provider track and account controlled substances?
5. Personal Hygiene and Skin Care
Does provider assess the patient’s skin integrity regularly for pressure ulcers?
Is provider keep the patient’s hygiene routine (bathing, oral care, hair care)?
Does provider change incontinence products regularly, and is the patient dry and clean?
Are pressure-relieving devices (mattresses, cushions) in place?
Does provider apply lotion to dry areas to prevent skin breakdown?
6. Nutrition and Hydration
Does provider staff document and follow dietary restrictions?
Is food intake documented as per care plan (e.g., calorie counts, fluid balance)?
Does provider schedule and follow meal times?
Is there access to water, and is the patient drinking enough fluids?
Does provider provide assistance during meals if the patient requires it?
Does provider administer and monitor enteral feeds (if applicable) correctly?
7. Mobility and Comfort
Does provider staff assess patient assessed for mobility needs?
Are mobility aids (e.g., walkers, wheelchairs) available and in good condition?
Does provider provide assistance for moving or repositioning as per the care plan?
Is pain assessed and managed effectively (pain scale documented)?
Does provider reposition the patient every two hours (if bed-bound) to prevent pressure sores?
8. Infection Control
Does provider follow hand hygiene protocols before and after patient contact?
Is the patient in the correct isolation level (if applicable)?
Does provider adhere to personal protective equipment (PPE) requirements?
Is wound care performed using sterile techniques?
Does provider change and document catheters, IVs, and dressings as per policy?
Does provider clean and disinfect patient care areas regularly?
9. Patient Communication and Emotional Well-being
Does provider staff orient the patient to time, place, and person?
Are patient’s concerns and questions addressed promptly?
Is there regular communication with the patient about their care plan?
Does provider staff involve family members or caregivers in care discussions if appropriate?
Does provider offer emotional support to the patient (psychosocial care, mental health services)?
Is the patient’s level of anxiety or distress assessed and managed?
10. Discharge Planning (if applicable)
Is there a discharge plan in place and communicated to the patient?
Does provider arrange follow-up appointments, and organize transportation?
Does provider provide medication instructions clearly for after discharge?
Is equipment or home care arranged if necessary?
Does provider provide discharge instructions to the patient and/or family members?
11. Documentation and Care Plan
Is the patient’s care plan up-to-date and accessible to the care team?
Does provider staff record progress notes regularly?
Are changes in condition documented and communicated to the healthcare team?
Does provider staff document informed consent for treatments and procedures?
Does provider staff store patient records securely?
12. Emergency Preparedness
Is the patient aware of emergency procedures?
Are emergency contact details up-to-date?
Are crash carts checked and nearby for patients at risk?
Is there a clear pathway for rapid response if the patient’s condition deteriorates?
13. Overall Patient Satisfaction
Is the patient satisfied with the care they are receiving?
Are there any complaints from the patient that need to be addressed?
Does provider document and act upon evidence of patient feedback?
Does provider staff prioritize the patient’s comfort and overall well-being?
14. Summary of Findings
Overall Status of Care: (Satisfactory, Needs Improvement, Non-compliant)
Follow-up Actions Required:
(List specific actions and responsible person/department)
Deadline for Corrective Actions:
Signature of Auditor:
Signature of Care Provider:
Patient Care Checklist is customizable based on the patient’s specific needs, care setting (hospital, long-term care, home care), or any regulatory and accreditation requirements. eAuditor Audits & Inspections can help track these audits, ensure compliance, assign follow-ups, and generate reports for continuous improvement in patient care quality.
eAuditor Audits & Inspections is a popular mobile inspection and auditing tool. It helps organizations streamline their audit processes, including those related to patient care, by allowing users to create Patient Care Checklist, conduct inspections, and generate reports on mobile devices. Here’s how you can use eAuditor Audits & Inspections for a Patient Care Audit:
Create or Select a Patient Care Checklist Template
You can either create a custom Patient Care Checklist audit template or select a pre-built Patient Care Checklist template from the eAuditor Audits & Inspections template library. Templates can include:
Patient hygiene checks
Medication administration protocols
Infection control measures
Patient safety checks
Care plan adherence
Medical equipment audits
Customize the Template Customize the audit template to align with the specific patient care protocols or regulatory requirements your healthcare facility follows. Add questions, multiple-choice options, and signature requirements where necessary.
Assign Audits to Staff Assign specific audits to healthcare providers or auditors in charge. You can schedule recurring audits or allow staff to conduct audits in real-time during patient rounds.
Conduct the Audit Use the mobile or desktop version of eAuditor Audits & Inspections to conduct the audit. Staff can:
Record responses directly into the app
Take photos to document any issues
Leave notes or comments about specific patient care concerns
Flag critical issues in real time
Generate Reports Once the audit is completed, eAuditor Audits & Inspections will automatically generate detailed reports. These reports can:
Highlight areas of non-compliance
Include a summary of actions taken or required follow-ups
Track trends over time to identify patterns in patient care issues
Analyze Data eAuditor Audits & Inspections’s analytics dashboard helps you visualize data over time. You can:
Track performance across departments or units
Measure adherence to patient care protocols
Identify areas that need improvement
Follow-Up and Implement Corrective Actions Based on the findings, follow up with the necessary actions. You can set reminders for follow-ups directly in eAuditor Audits & Inspections to ensure that issues are addressed in a timely manner.
Continuous Improvement Use the insights from eAuditor Audits & Inspections to continuously refine patient care practices, improve compliance, and ensure high standards of patient safety and well-being.
Aging-in-place HomeFit Aging-in-place HomeFit using eAuditor Audits & Inspections refers to using the app to assess the accessibility, functionality, and safety of […]
Terminal Cleaning Checklist Creating a Terminal Cleaning Checklist using the eAuditor Audits & Inspections app helps ensure comprehensive and systematic cleaning, particularly in […]