POLICY & PROCEDURE COMPLIANCE
AUDIT TOOL
A structured framework for identifying policy violations, compliance gaps, and systemic failures across all healthcare settings.
Policies and procedures define the minimum standard of care within a healthcare facility. When staff fail to follow these written requirements, the deviation becomes one of the strongest forms of breach evidence.
This tool helps attorneys compare facility policies to actual care delivered, identify compliance failures, and uncover systemic issues that contributed to patient harm.
Use it during case screening, breach analysis, expert preparation, and deposition strategy.
IDENTIFY APPLICABLE POLICIES
✔ Gather All Relevant Policies
• Admission and assessment
• Change in condition
• Provider notification
• Medication administration
• Wound care
• Fall prevention
• Infection control
• Documentation standards
• Escalation and transfer
• Staffing and supervision
• Handoff communication
• Emergency response
✔ Confirm Policy Versions
• Policy in effect at the time of the incident
• Revision history
• Whether staff were trained on the current version
COMPARE POLICY REQUIREMENTS TO ACTUAL CARE
✔ Extract Key Policy Requirements
• Required assessments
• Required monitoring frequency
• Required interventions
• Required documentation
• Required provider notification
• Required escalation steps
• Required handoff element
✔ Compare to What Actually Happened
• Was the assessment performed?
• Was monitoring completed on schedule?
• Were interventions timely?
• Was documentation complete?
• Was the provider notified?
• Was escalation appropriate?
ADMISSION & BASELINE COMPLIANCE
✔ Audit for Required Admission Elements
• Baseline assessment
• Medication reconciliation
• Skin assessment
• Fall risk assessment
• Cognitive status
• Functional status
• Care plan initiation
✔ Identify Violations
• Missing baseline assessments
• No medication reconciliation
• No care plan created
• Incomplete or contradictory documentation
CHANGE IN CONDITION COMPLIANCE
✔ Required Policy Steps
• Recognize change
• Assess patient
• Notify provider
• Document notification
• Receive orders
• Implement interventions
• Reassess
• Notify family
• Escalate if needed
✔ Identify Violations
• Delayed recognition
• No provider notification
• No reassessment
• No documentation of communication
• No escalation despite red‑flag symptom
MEDICATION POLICY COMPLIANCE
✔ Required Elements
• Accurate MAR
• Timely administration
• PRN documentation
• Side effect monitoring
• Controlled substance handling
• Pharmacy communication
✔ Identify Violations
• Missed or late doses
• No documentation of PRN effectiveness
• No monitoring for side effects
• Medication discrepancies
WOUND CARE POLICY COMPLIANCE
✔ Required Elements
• Initial wound assessment
• Measurements
• Dressing changes
• Infection monitoring
• Provider notification
• Reassessment schedule
✔ Identify Violations
• No measurements
• No progression documentation
• No provider notification of deterioration
TRANSFER & HANDOFF COMPLIANCE
✔ Required Handoff Elements
• Reason for transfer
• Vitals
• Labs
• Medications
• Recent changes in condition
• Interventions performed
• Pending orders
• Safety risks
✔ Identify Violations
• Missing handoff
• Incomplete handoff
• Contradictory information
• No documentation of communication
GLOBAL POLICY VIOLATION RED FLAGS
• Staff unaware of policy requirements
• Policy not followed
• Policy outdated or inconsistent with regulations
• No documentation of required steps
• Contradictory entries
• Late entries without explanation
• No evidence of staff training
• No follow‑up after abnormal findings
• No escalation despite policy requirements
These are some of the strongest breach indicators in healthcare negligence cases.