Patient Care Checklist

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.