WARD Audit Checklist as per 5th edition NABH standards

Quick list

• Initial assessment & reassessment

• Care plan

• Nursing care according to current standard of Practice

• CPR- Assigned Roles and Responsibilities

• Documentation of hand-over

• Safe transfer of patients

• Pain management

• Nutritional assessment

• Blood transfusion

• Vulnerable patients

• Patients' rights displayed- right to respect for values and belief

• Patient feedback

• Medical gas

• Equipment / furniture maintenance

• Medication reconciliations

• Monitoring of patients after medication administration

• Appropriate and adequate equipment

• Admission process

• Planned discharges

• Discharge & discharge Summary

• Early warning signs

• Case records — documentation

• Referrals

• Physician's sample drugs

• Medication orders

• Medication management

• Narcotics

• Restraint policy

• Hazmat

• Fire safety

• BMW • Infection control

• Hand hygiene

• DVT

• Pressure ulcers

• Patient Experience

AAC 4 a-i	• • • • • •	Predefined initial assessment Time frame for doing and documenting initial assessment Initial assessment to include screening for nutritional needs Initial Nursing Assessment Plan of care includes desired outcomes Plan of care countersigned by clinician in charge within 24 hours
AAC 5 a, c, d, e	•	Reassessment — frequency of reassessment, documentation, response to treatment, plan for further treatment or discharge
	•	Monitoring of plan of care, modification where found necessary
AAC 5 f	•	Identifies early warning signs.(MEWS)
	•	Staff training
AAC 12 a-i	•	Qualified individual identified as responsible for the patient's care
	•	Multidisciplinary care & co-ordination among various depts. / staff / shifts
	•	Structured handing / taking over by doctors & nurses, and documentation
	•	Transfer of patients between departments/units. Referrals
	•	Adequate clinical intervention in response to a critical alert
AAC 13 a-e	•	Discharge planning (atleast 24 hrs in advance) in consultation with patient, family, coordinating with various depts.., including MLCs
	•	Summary given to all including LAMA and discharge on request
	•	Defines time taken for discharge; monitors delay
AAC 14 a-g	•	Content of discharge summary. Receipt acknowledged
COP 1 a, d	•	Uniform care; evidence based medicine & clinical practice guidelines

COP 5 a, b e	•	CPR — Policy and procedure, staff trained in CPR, Documentation of events during CPR, Communication of CAPA measures, assigned roles and responsibilities are complied with.
COP 6 a-g	•	Documented policies and procedures for Nursing Services
	•	Assignment of patient care as per current standard of practice
	•	Nursing care is aligned and integrated with overall patient care
	•	Nursing Plan of Care documented in the patient record
	•	Provision of adequate equipment
	•	Empowerment for nursing related decisions
COP 7 a-g	•	Documented procedures of various clinical procedures
	•	Qualifications of the personnel, who are performing procedures
	•	Prevention of adverse events - wrong site, patient and procedure
	•	Informed consent taken by the doctor performing the procedure
	•	Adherence to standard precautions and asepsis
	•	Monitoring of patients during and after the procedure
	•	Documentation of the procedures accurately in the patient record
COP 8 b, d, g.	•	Scope of transfusion services
11	•	Rational use of blood and blood products; transfusion
	•	Informed consent
	•	Monitoring transfusion reactions; post transfusion forms
	•	Staff awareness on above policies
	•	Quality Assurance Programme
COP 14 a-d	Q	Care of patients undergoing surgeries — policies & procedures, preop assessment, provisional diagnosis prior to surgery, informed consent, procedures to prevent adverse events, post op care plan documented, Surgical Safety Checklist
COP 16	•	Care of vulnerable patients
	•	Pressure ulcer
	•	DVT —
	•	Policies & procedures on the care of patients under restraints
	•	Documentation of reasons for restraints; monitoring and frequency
	•	Staff awareness on control and restraint techniques; monitoring
COP 17 a-e	•	Policies & procedures on pain management
	•	Pain screening; pain assessment and periodic re-assessment
	•	Pain alleviation methods initiated and monitored for response
	•	Education of patient and/or family on pain management techniques
COP 19 a-f	•	Nutritional assessment and reassessment
	•	Written Order for diet; food as per patient's clinical needs
	•	Planning of nutritional therapy
	•	Patient and/or family's education on the patient's diet limitations
	•	Food is stored and distributed safely
	•	Mechanism for physician's sample
MOM 3 c, b-g	•	Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications
MOM 4 a-i	•	Prescription of medicines (CAPITAL letters)
	•	Medication orders
	•	High risk medications defined
	•	Verbal orders
MOM 4 C & h	•	Previous ADRs
	•	Drug reconciliation

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