MONTHLY RANDOM CARE PLAN AUDIT
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Name of Resident:
Resident ID present and up-to-date.
Resident's front sheet present and up-to-date.
Resident's assessments present and up-to-date.
Resident's global care plan present and up-to-date.
Resident's care plan present and up-to-date.
Resident's evaluations present and up-to-date.
Resident's daily notes present and up-to-date.
Resident's DNR present and up-to-date.
Care plan present for each identified and assessed problem, need and goal.
Care plan is realistic, attainable and effective as far as possible.
Care is given effectively from the information in each care plan.
Care plan evaluations indicate it has really been considered and is still
relevant.
Evidence available that care plan has been updated or replaced if evaluation
indicates need.
DNR present and in date in an acceptable and legal condition.
Is there an Advanced Directive or EOL care wishes.
DOLS application been made if appropriate.
Capacity assessment in place.
Assessments and care plans are evaluated consistently within an acceptable
time frame.
MANAGER SIGN…………………………………
DATE…………………