YOUR REVIEW WORKSPACE

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22 DOCUMENT TYPES

Required document audit

Check presence and content completeness for each document. Use N/A when it does not apply.

Two checks for each document

Quantitative: is it present? Qualitative: is the content complete? N/A is excluded from the scores. A missing document cannot receive a quality assessment.

22 document types shown · 0/22 assessed

01

Consent for Admission & Treatment (General Consent)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

02

Initial Assessment (Physician)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

03

Initial Assessment (Nursing)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

04

Fall Risk Assessment / Re-assessment

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

05

Plan of Care (Physician / Interdisciplinary)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

06

Medication Reconciliation (Admission & Discharge)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

07

VTE Risk Assessment Form

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

08

Physician Order

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

09

Physician Progress note

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

10

Handover (Physician)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

11

Handover (Nursing)

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

12

Pre-Anesthesia Assessment

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

13

Anesthesia/ Sedation Consent

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

14

Pre-operative check list

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

15

Surgical consent

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

16

Surgical safety checklist

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

17

Operation notes

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

18

Anesthesia Record & Recovery (PACU) Record

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

19

Consent for Blood/ Blood components transfusion

Procedures & transfusion

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

20

Consultation documentation

Admission & care

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

21

Transcribed discharge summary

Discharge & mortality

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

22

Mortality summary

Discharge & mortality

Quantitative Document presence

Qualitative Content completeness

Mark the document present to assess its quality.

22 documents remainingSave to the team workspace, or complete for KPIs.