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ICU Audit checklist

Patient Assessment

Vital signs are recorded every 4 hours

Record temperature, heart rate, respiratory rate, and blood pressure
Document findings accurately in patient's chart

Glasgow Coma Scale is documented every shift

Perform assessment using standardized tool
Document level of consciousness score

Pain assessment is completed regularly

Use pain scale to assess patient's pain level
Document pain score and interventions

Skin integrity is checked and documented daily

Inspect skin for any redness, breakdown, or pressure injuries
Document findings and interventions

Neurological status is monitored and documented

Assess pupil size and reactivity
Document any changes in neurological status

Assessment of respiratory status, including oxygen saturation levels and respiratory rate

Measure oxygen saturation levels
Monitor respiratory rate and effort

Assessment of cardiac status, including heart rate, blood pressure, and ECG monitoring

Check heart rate and blood pressure regularly
Perform ECG monitoring as ordered

Assessment of renal function, including urine output and serum creatinine levels

Measure urine output accurately
Monitor serum creatinine levels

Assessment of gastrointestinal function, including bowel sounds and abdominal distension

Listen for bowel sounds in all quadrants
Assess for abdominal distension

Assessment of fluid balance, including input and output monitoring

Record all intake including IV fluids and oral intake
Measure and document all output including urine, vomit, and drainage

Assessment of nutritional status and feeding tolerance

Assess patient's appetite and ability to tolerate feeds
Monitor weight changes and nutritional lab values

Assessment of mobility and risk for pressure ulcers

Assess patient's ability to move and reposition as needed
Check skin for any signs of pressure ulcers

Assessment of psychological and emotional well-being

Assess patient's emotional state and coping mechanisms
Provide emotional support as needed

Assessment of any changes in mental status or level of consciousness

Document any changes in patient's mental status
Report any concerns to the healthcare team

Medication Management

Medication orders are signed by a physician

All medications are double-checked before administration

Controlled substances are accurately documented

Medication reconciliation is completed upon admission and discharge

IV medications are labeled correctly

Medication administration is documented in the patient's chart

High-alert medications are properly stored and secured

Medication errors are reported and investigated

Patients are educated on their medications and potential side effects

Medication expiration dates are routinely checked and expired medications are disposed of properly

Infection Control

Hand hygiene protocols are followed by all staff

Isolation precautions are implemented when necessary

Central line dressings are changed according to policy

Ventilator-associated pneumonia prevention bundle is followed

Environmental cleaning is performed regularly

Personal protective equipment is used appropriately by staff

Proper disposal of biohazardous waste is observed

Compliance with hospital policies for preventing healthcare-associated infections

Regular monitoring and surveillance of infection rates within the ICU

Proper management and disposal of infectious waste

Staff are educated on infection control practices and protocols

Compliance with protocols for antibiotic stewardship

Equipment and Supplies

Ventilator settings are checked and documented

Emergency equipment is readily available and in working order

Suction equipment is maintained and functioning properly

IV pumps are calibrated and alarms are set

Bedside monitors are monitored and alarms are responded to promptly

Crash cart is fully stocked and easily accessible

Oxygen tanks are adequately filled and easily accessible

Defibrillator is regularly checked and charged

Central line insertion kits are readily available

Patient beds are in good working condition

Glucometer and other point-of-care testing equipment are properly calibrated

Isolation carts are stocked with necessary supplies for infection control

Documentation

All entries in the medical record are dated and timed

Physician progress notes are completed daily

Nursing assessments are completed on admission and every shift

Discharge instructions and follow-up appointments are documented

Incident reports are completed for any adverse events

All orders are signed and dated by the ordering physician

Consents for procedures and surgeries are properly documented

Patient education materials and teaching sessions are documented

Consultation reports from specialists are filed in the medical record

All lab and diagnostic test results are documented in the medical record

All allergies and medication reactions are clearly documented

Staffing and Training

Staffing levels are appropriate for patient acuity

Staff receive regular training on ICU protocols and procedures

Competency assessments are completed annually

Staffing assignments are based on skill level and experience

Staff morale and communication are regularly assessed and addressed

Staffing assignments are reviewed and adjusted as needed to ensure optimal patient care

Staffing levels are consistently monitored and adjusted based on patient census and acuity

Staff participate in ongoing education and training to stay current on best practices in critical care

Staff are cross-trained in multiple areas of the ICU to ensure flexibility and coverage during peak times

Staffing schedules are created with consideration for staff fatigue and burnout prevention

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