Health Services Task Audit Form
Use this form to systematically audit and evaluate the completion and quality of health service tasks.
Auditor Full Name
*
First Name
Last Name
Auditor Email Address
*
example@example.com
Facility/Unit Name
*
Date of Audit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Audit
*
Hour Minutes
AM
PM
AM/PM Option
Type of Health Service Audited
*
Please Select
Inpatient Care
Outpatient Care
Emergency Services
Surgical Services
Laboratory Services
Other
Task Compliance Assessment
*
Rows
Compliant
Partially Compliant
Non-Compliant
Not Applicable
Hand hygiene performed correctly
1
2
3
4
Patient identification verified
5
6
7
8
Medication administration documented
9
10
11
12
Equipment sanitized before use
13
14
15
16
Waste disposed of properly
17
18
19
20
Patient privacy maintained
21
22
23
24
Overall Quality of Health Service Tasks
*
1
2
3
4
5
Were any incidents or issues observed during the audit?
*
No issues observed
Yes, issues observed
If issues were observed, please describe them below.
Additional Comments or Recommendations
Auditor Signature (confirming accuracy of this audit)
*
Submit Audit
Submit Audit
Should be Empty: