Informed Consent Audit

Complete per audit schedule.

  • Industry: Healthcare
  • Frequency: Periodic
  • Estimated Time: 30-45 minutes per record
  • Role: Risk / Compliance
  • Total Items: 30
  • Compliance: Joint Commission, State Regulations

Consent Documentation

Check consent.

  • Consent form present?
  • Properly signed and dated?
  • Risks/benefits documented?

Pre-Assessment Information

Initial assessment documentation and patient/facility identification

  • Assessor Name / Credentials
  • Assessment Date
  • Department / Unit
  • Assessment Type (Routine/Annual/Complaint)
  • Previous assessment findings reviewed?

Infection Prevention & Control

Verify infection control practices per CDC and Joint Commission standards

  • Hand hygiene compliance observed?
  • Appropriate PPE available and properly used?
  • Isolation precautions properly implemented?
  • Sharps containers available and not overfilled?
  • High-touch surfaces properly disinfected?

Patient Safety & Identification

Verify patient safety protocols and identification procedures

  • Two patient identifiers used before procedures?
  • Fall risk assessment completed?
  • Call light within patient reach?
  • Bed in lowest position with brakes locked?

Medication Safety & Management

Verify medication handling and administration practices

  • Medications stored securely and at proper temperature?
  • Controlled substances properly secured and counted?
  • No expired medications in stock?
  • High-alert medications properly labeled?

Environment of Care & Safety

Verify facility environment meets safety standards

  • Fire exits clear and unobstructed?
  • Emergency equipment functional and accessible?
  • Spill kits available and stocked?
  • Electrical cords and outlets in safe condition?

Documentation & Regulatory Compliance

Complete assessment documentation and ensure regulatory compliance

  • All findings documented with evidence?
  • Corrective actions assigned with timeline?
  • Staff education provided on identified issues?
  • Assessor Signature
  • Additional Observations

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