Table 2.

Updated nursing documentation auditing checklist

No	Structure	Complete record	Incomplete record	No record	Not necessary
1	Patient demographic data
2	Unclear terms
3	Estimates and assumptions
4	Unauthorized abbreviation
5	Repetitive issue
6	Use braces and parentheses to add new content
7	Leave space
8	Use correct writing
9	Appropriate medical terminology
10	Legible, clean and tidy recording
11	Coherence and relevance of reported
12	Writing with black or blue pen
13	Written by two different people
14	Write the exact time of 24 hours
15	Mistakes
16	To finish correctly
	• nurse name
	• nurse surname
	• nurse position
	• nurse degree
	• exact date
	• exact hour
	• stamp of name along with the number of nursing
	• signature
	• draw a line across the useable space before and after the signing
No	Content
1	Urinary status
2	Bowel movement
3	Sleep and rest
4	Diet and appetite
5	Activity
6	Vital signs in chart
7	Pain
8	Patient teaching
9	Follow up issue
10	Radiography
11	Laboratory tests
12	Transferring patients to the operating room
	• Time of departure for surgery
	• Time back
	• General condition of the patient after surgery
13	Transferring patients to other wards or hospitals
	• Transfer time
	• How transferring
	• Staff who accompany patient
14	Reason of not doing an order
15	Telephone orders
16	Safety devices such as bedside rails
17	Essential information about medications
	• Drug name
	• Type of drug
	• Drug dosage
	• Time of administration
	• Route of administration
	• Intravenous fluids’ number of drops
	• Intravenous fluids administration: Start time
	• Intravenous fluids administration: Time off
	• Patient’s response to medication
18	Detailed record of the events that happened to the patient like cardiopulmonary resuscitation
19	Nursing care or observation