Explore our Quality Assurance Nurse Checklist Table, your guide to holistic patient care, from initial assessment to treatment response and education.
1
Review patient's medical history
2
Conduct patient assessment
3
Record patient's vital signs
4
Approval: Patient Assessment
5
Manage patient care plan
6
Coordinate with other healthcare professionals
7
Perform clinical tasks
8
Monitor patient's response to treatment
9
Approval: Treatment Response
10
Report changes to the physician
11
Document all care information concisely
12
Observe patient’s physical, mental, and emotional conditions
13
Communicate with patient and family members
14
Administer medications and treatments to patients
15
Approval: Medication Administration
16
Review and revise care plans as needed
17
Maintain patient confidentiality
18
Ensure equipment is in working order
19
Prepare patients for examinations or treatments
20
Provide education to patients and families
Review patient's medical history
Review the patient's medical history to gain a comprehensive understanding of their past illnesses, surgeries, allergies, and medications. This information is vital for providing appropriate care and treatment. Ensure that the medical history is up to date, accurate, and easily accessible in the patient's records.
1
None
2
1-3 medications
3
4-6 medications
4
7-10 medications
5
More than 10 medications
1
None
2
Food allergies
3
Medication allergies
4
Environmental allergies
5
Other allergies
Conduct patient assessment
Conduct a comprehensive assessment of the patient's physical, mental, and emotional well-being. This includes evaluating their symptoms, pain levels, mobility, cognitive function, and overall health status. Use various assessment tools and techniques to gather accurate data for diagnosis and treatment planning.
1
Pain assessment
2
Mobility assessment
3
Cognitive assessment
4
Emotional assessment
5
Overall health assessment
Record patient's vital signs
Regularly record and monitor the patient's vital signs to assess their overall health and detect any abnormalities. Vital signs include blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation level. Accurate recording of vital signs helps in identifying changes or trends that may require prompt intervention.
Approval: Patient Assessment
Will be submitted for approval:
Conduct patient assessment
Will be submitted
Manage patient care plan
Develop and manage an individualized care plan for each patient based on their specific needs, goals, and preferences. The care plan should outline the interventions, treatments, and medications required to promote the patient's health and well-being. Regularly review and update the care plan as needed to ensure its effectiveness.
Coordinate with other healthcare professionals
Collaborate and effectively communicate with other healthcare professionals involved in the patient's care, such as physicians, therapists, and social workers. Ensure seamless coordination to deliver comprehensive and cohesive care. Share relevant information, discuss treatment plans, and seek inputs from the interdisciplinary team to optimize patient outcomes.
Perform clinical tasks
Perform various clinical tasks as required to assist in the delivery of patient care. These tasks may include wound dressing, medication administration, specimen collection, IV therapy, catheter insertion, and other medical procedures. Adhere to established protocols, guidelines, and infection control measures while performing these tasks.
1
Wound dressing
2
Medication administration
3
Specimen collection
4
IV therapy
5
Catheter insertion
1
Urgent
2
High
3
Medium
4
Low
5
Not applicable
Monitor patient's response to treatment
Regularly monitor and assess the patient's response to the ongoing treatment plan. Evaluate their progress, symptoms, and any changes in their condition. Promptly identify and report any adverse reactions or unexpected outcomes to the healthcare team. Make necessary modifications to the treatment plan based on the patient's response and needs.
1
Reduced pain
2
Increased mobility
3
Improved cognitive function
4
Improved emotional well-being
5
Worsening symptoms
Approval: Treatment Response
Will be submitted for approval:
Monitor patient's response to treatment
Will be submitted
Report changes to the physician
Communicate any significant changes in the patient's condition or unexpected outcomes to the physician responsible for their care. Provide detailed and accurate information about the changes, symptoms, and any interventions implemented. Collaborate with the physician to determine the appropriate course of action and adjustments to the treatment plan.
Document all care information concisely
Accurately and concisely document all care-related information in the patient's medical records. Include details about assessments, interventions, treatments, medications, vital signs, and any changes in the patient's condition. Follow the established documentation standards and ensure that the information is legible, organized, and easily accessible for future reference.
Observe patient’s physical, mental, and emotional conditions
Pay close attention to the patient's physical, mental, and emotional conditions during each interaction. Observe for any signs of discomfort, distress, anxiety, confusion, or depression. Promptly address any concerns or changes in the patient's condition and provide appropriate support or interventions as needed.
1
Physical condition
2
Mental condition
3
Emotional condition
Communicate with patient and family members
Effectively communicate with the patient and their family members to provide information, support, and reassurance. Listen attentively to their concerns, answer questions, and explain procedures, treatments, and medications in a clear and easily understandable manner. Foster a compassionate and empathetic environment to promote patient engagement and shared decision-making.
