OROMIA REGIONAL HEALTH

BUREAU

Agaro General Hospital

Nursing Audit Team

Term of Reference (Tor)

Meskerem,2017 EC.

By:Tofik W(Matron)

Table of content
INTRODUCTION.....................................................3

GosterWalfer stated that.......................................3

**Terms of Reference for Nursing Audit Team**......4

**1. Purpose**....................................................................4

**2. Scope**.......................................................................4

**3. Key Areas of Focus**...................................................5

**4. Responsibilities of the Nursing Audit Team**..............7

**5. Methodology**............................................................7

The nursing audits are mainly of 3 types................8

1. Concurrent audit...............................................8

2. Retrospective audit...........................................8

3. Prospective audits............................................8

**6. Expected Outcomes**.................................................8

**7. Reporting Structure**.................................................9

**8. Team Composition**...................................................9

**9. Ethical Considerations**...........................................10

**10. Continuous Improvement**.....................................10

**Final Note**:....................................................11

Ammending the terms of Referrance...............................11

INTRODUCTION

Nursing audit is an evaluation of nursing service. Before

1955 very little was known about the concept. It was
introduced by the industrial concern and the year 1918
was the beginning of medical audit.
George Groword, pronounced the term physician for the
first time medical audit. Ten years later Thomas R Pondon
MD established a method of medical audit based on
procedures used by financial account. He evaluated the
medical care by reviewing the medical records.
First report of nursing audit of the hospital published in
1955. For the next 15 years, nursing audit is reported from
study or record on the last decade. The program is
reviewed from record nursing plan, nurse’s notes, patient
condition, nursing care.
The nursing/midwifery practice audit programme should
be part of the overall hospital quality improvement
programme. Nursing/midwifery practice audit is one of
the tools to ensure the clinical effectiveness of
nursing/midwifery care patients/clients receive.
Elison “Nursing audit refers to assessment of the quality
of clinical nursing”.
GosterWalfer stated that
a. Nursing Audit is an exercise to find out whether good

nursing practices are followed.

b. The audit is a means by which nurses themselves can

define standards from their point of view and

describe the actual practice of nursing.
 **Terms of Reference for Nursing Audit
Team**
The Nursing Audit Team is established to evaluate and
improve the quality of nursing care provided within the
healthcare facility. The audit focuses on key aspects of
nursing practice, including the quality of the nursing
process, patient monitoring, pain management,
medication administration, and client education. Below are
the terms of reference for the team:

**1. Purpose**

The purpose of the Nursing Audit Team is to:

- Assess the quality of nursing care delivered to patients.
- Identify areas of strength and opportunities for
improvement in nursing practices.
- Ensure compliance with evidence-based standards,
policies, and protocols.
- Enhance patient safety, satisfaction, and clinical
outcomes.

**2. Scope**

The audit will focus on the following key areas:

1. **Quality of the Nursing Process**
2. **Patient Monitoring**
3. **Pain Management**
4. **Medication Administration**
5. **Client Education**

These components will be evaluated through systematic

data collection, analysis, and feedback mechanisms.

**3. Key Areas of Focus**

**a. Quality of the Nursing Process**

- Evaluate adherence to the nursing process: assessment,
diagnosis, planning, implementation, and evaluation.
- Assess the accuracy and completeness of nursing
documentation.
- Review individualized care plans to ensure they meet
patient needs and align with evidence-based practices.
- Identify gaps or inconsistencies in the application of the
nursing process.

**b. Patient Monitoring**

- Assess the frequency and thoroughness of patient
assessments (e.g., vital signs, physical examinations, and
mental status evaluations).
- Evaluate the use of monitoring tools and technologies
(e.g., telemetry, pulse oximetry).
- Ensure timely identification and reporting of changes in
patient condition to the healthcare team.
- Review protocols for high-risk patients (e.g., those with
sepsis, postoperative complications, or chronic
conditions).

**c. Pain Management**

- Evaluate the effectiveness of pain assessment using
standardized tools (e.g., Numeric Rating Scale, Wong-
Baker Faces Pain Scale).
- Assess the timeliness and appropriateness of pain
interventions (e.g., pharmacological and non-
pharmacological methods).
- Review documentation of pain reassessment after
interventions.
- Ensure patient education on pain management strategies
is provided.

**d. Medication Administration**

- Assess compliance with the "Five Rights" of medication
administration: right patient, right drug, right dose, right
route, and right time.
- Evaluate the accuracy and completeness of medication
documentation.
- Review processes for medication reconciliation during
transitions of care (e.g., admission, transfer, discharge).
- Identify and address any errors or near misses in
medication administration.

**e. Client Education**

- Evaluate the provision of patient education on diagnoses,
treatments, medications, and self-care practices.
- Assess the use of clear, culturally sensitive
communication techniques.
- Review documentation of patient understanding and
engagement in their care plan.
- Ensure that educational materials are accessible and
tailored to the patient’s literacy level and language
preferences.

**4. Responsibilities of the Nursing Audit

Team**

- **Data Collection**: Gather information through chart

reviews, direct observation, interviews with staff and
patients, and feedback from interdisciplinary teams.
- **Analysis**: Analyze data to identify trends, strengths,
and areas for improvement.
- **Reporting**: Prepare detailed reports summarizing
findings, including recommendations for improvement.
- **Feedback**: Provide constructive feedback to nursing
staff and leadership.
- **Action Planning**: Collaborate with stakeholders to
develop and implement action plans for addressing
identified issues.
- **Follow-Up**: Monitor progress and evaluate the
impact of interventions over time.
 **5. Methodology**

**a. Data Sources**

- Medical records and nursing documentation.
- Direct observations of nursing practices.
- Patient and family feedback surveys.
- Incident reports and quality metrics.

**b. Audit Tools**

- Standardized checklists and scoring systems for each
focus area.
- Evidence-based guidelines and best practices.
- Facility-specific policies and procedures.
The nursing audits are mainly of 3 types
1. Concurrent audit
2. Retrospective audit
3. Prospective audits

**c. Frequency**
- Conduct audits quarterly or as needed based on
organizational priorities.
- Perform focused audits on specific areas (e.g., pain
management) as required.

**6. Expected Outcomes**

- Improved adherence to evidence-based nursing

practices.
- Enhanced patient safety and satisfaction.
- Reduction in adverse events (e.g., medication errors,
falls, pressure ulcers).
- Increased staff competence and confidence in delivering
high-quality care.
- Strengthened interdisciplinary collaboration and
communication.

**7. Reporting Structure**

- The Nursing Audit Team will report directly to the

matron.
- Findings and recommendations will be shared with the
nursing leadership team, quality assurance committee,
and other relevant stakeholders.
- Progress updates will be provided at regular intervals
(e.g., monthly or quarterly meetings).

**8. Team Composition**

The Nursing Audit Team will consist of:

- **Team Leader**: A senior nurse or nurse manager with
expertise in quality improvement.
- **Quality Assurance Representative**: To ensure
alignment with organizational goals.
# Name Working area (Ward) Comments

1 Mr. TofikWudad Matron Chair man

2 Mr. ZeynuTemam Vice Matron Secretary

3 Mr.Hikem Muhidn Nurse Supervisor Member

4 Mr. Abdulaziz A/Gero OPD Head Nurse Member

5 Mr.Muaz Qasima EOPD Head Nurse Member

6 Mr. Medina Alemu Labor ward Head Member

7 Mr. Adisu Sisay NICU Head Nurse Member

8 Mr. Mahdi Abdulkarim Medical Ward Head Member

9 Mr.Seid Kedir Pediatrics Ward Head Member

10 Mr.Ahmed Taju ICU Head Nurse Member

**9. Ethical Considerations**

- Maintain confidentiality of patient and staff information.

- Ensure transparency and fairness in the audit process.
- Use findings constructively to support professional
development and system improvements, not for punitive
measures.

**10. Continuous Improvement**

The Nursing Audit Team will:
- Stay updated on emerging best practices and regulatory
requirements.
- Incorporate feedback from staff and patients to refine
the audit process.
- Promote a culture of continuous learning and quality
improvement.
By adhering to these terms of reference, the Nursing Audit
Team will play a critical role in ensuring the delivery of
safe, effective, and patient-centered nursing care.

**Final Note**:
These terms of reference should be reviewed and updated
periodically to reflect changes in organizational priorities,
regulations, and industry standards.

Ammending the terms of Referrance

Any section or part of the TOR is subject to change at any time based on
the decision or recommendation of the committee or SMT.

Referrance
Marquis, B. L., & Huston, C. J. (2021). Leadership Roles and
Management Functions in Nursing: Theory and Application (10th
ed.). Wolters Kluwer.
Huber, D. L. (2021). Leadership and Nursing Care Management
(7th ed.). Elsevier
Grove, S. K., Burns, N., & Gray, J. R. (2013). The Practice of
Nursing Research: Appraisal, Synthesis, and Generation of
Evidence (7th ed.). Elsevier.
 **Nursing Audit Questionnaires for the Terms of
Reference (TOR)**

**1. Quality of the Nursing Process**

**Assessment**
- Were the patient’s physical, psychological, and social
needs assessed upon admission?
- [ ] Yes
- [ ] No
- If no, what was missing?
_______________________________________

- Was a comprehensive nursing assessment documented

within the required timeframe (e.g., 24 hours)?
- [ ] Yes
- [ ] No

- Was the assessment individualized to the patient’s

condition and needs?
- [ ] Yes
- [ ] No

**Diagnosis**
- Were nursing diagnoses clearly identified and
documented in the care plan?
- [ ] Yes
- [ ] No
- If no, specify the issue:
_______________________________________
**Planning**
- Was a care plan developed based on the nursing
diagnoses?
- [ ] Yes
- [ ] No

- Were measurable goals and outcomes included in the

care plan?
- [ ] Yes
- [ ] No

**Implementation**
- Were interventions implemented as per the care plan?
- [ ] Yes
- [ ] No
- If no, specify the deviations:
___________________________________

**Evaluation**
- Were outcomes evaluated and documented regularly?
- [ ] Yes
- [ ] No
- Were adjustments made to the care plan based on
evaluation findings?
- [ ] Yes
- [ ] No

**2. Patient Monitoring**

**Vital Signs**
- Were vital signs monitored at the prescribed frequency
(e.g., every 4 hours for stable patients)?
- [ ] Yes
- [ ] No
- If no, how often were they monitored?
____________________________

- Were abnormal vital signs reported to the healthcare

provider promptly?
- [ ] Yes
- [ ] No

**Physical Assessment**
- Was a head-to-toe physical assessment conducted
during each shift?
- [ ] Yes
- [ ] No
- Were any abnormalities documented and addressed?
- [ ] Yes
- [ ] No

**High-Risk Patients**
- Were high-risk patients (e.g., postoperative, ICU, or
elderly) monitored more frequently?
- [ ] Yes
- [ ] No
- Specify monitoring tools used:
___________________________________

**Changes in Condition**
- Were changes in the patient’s condition (e.g., confusion,
pain, or vital sign fluctuations) documented and reported
promptly?
- [ ] Yes
- [ ] No

**3. Pain Management**

**Pain Assessment**
- Was pain assessed using a standardized tool (e.g.,
Numeric Rating Scale, Wong-Baker Faces)?
- [ ] Yes
- [ ] No
- Specify the tool used:
___________________________________________

- Was pain assessed at regular intervals (e.g., every 4

hours for hospitalized patients)?
- [ ] Yes
- [ ] No

**Interventions**
- Were appropriate interventions (pharmacological and
non-pharmacological) provided based on pain scores?
- [ ] Yes
 - [ ] No
- Specify interventions used:
______________________________________

- Were pain reassessments conducted after interventions?

- [ ] Yes
- [ ] No

**Patient Education**
- Was the patient educated about pain management
strategies?
- [ ] Yes
- [ ] No
- Did the patient demonstrate understanding of these
strategies?
- [ ] Yes
- [ ] No

**4. Medication Administration**

**Five Rights**
- Were the "Five Rights" of medication administration
followed?
- Right Patient: [ ] Yes [ ] No
- Right Drug: [ ] Yes [ ] No
- Right Dose: [ ] Yes [ ] No
- Right Route: [ ] Yes [ ] No
- Right Time: [ ] Yes [ ] No

- Were medications administered within the prescribed

time frame (± 30 minutes)?
- [ ] Yes
- [ ] No

**Documentation**
- Was medication administration documented accurately
and promptly?
- [ ] Yes
- [ ] No
- Were any discrepancies noted? Specify:
____________________________
 **Medication Reconciliation**
- Was medication reconciliation performed during
admission, transfer, and discharge?
- Admission: [ ] Yes [ ] No
- Transfer: [ ] Yes [ ] No
- Discharge: [ ] Yes [ ] No

**Errors and Near Misses**

- Were there any medication errors or near misses
reported during the audit period?
- [ ] Yes
- [ ] No
- Specify details:
________________________________________________

**5. Client Education**

**Content Delivery**
- Was the patient educated about their diagnosis,
treatment plan, and medications?
- Diagnosis: [ ] Yes [ ] No
- Treatment Plan: [ ] Yes [ ] No
- Medications: [ ] Yes [ ] No

- Were educational materials provided in the patient’s

preferred language and literacy level?
- [ ] Yes
- [ ] No

**Teaching Methods**
- Were teaching methods appropriate for the patient’s
learning style (e.g., verbal, written, demonstration)?
- [ ] Yes
- [ ] No
- Specify methods used:
___________________________________________

**Patient Understanding**
- Did the patient demonstrate understanding of the
information provided?
- [ ] Yes
 - [ ] No
- How was understanding assessed (e.g., teach-back
method)? ___________

**Family Involvement**
- Was the family involved in the education process when
applicable?
- [ ] Yes
- [ ] No

**6. General Questions**

**Staff Competency**
- Are nurses trained and competent in the areas being
audited (e.g., pain management, medication
administration)?
- [ ] Yes
- [ ] No

**Compliance with Policies**

- Were facility policies and procedures followed
consistently?
- [ ] Yes
- [ ] No

**Patient Satisfaction**
- Did the patient express satisfaction with the care
received?
- [ ] Yes
- [ ] No
- Specify feedback:
_______________________________________________