Patient Identification Audit Form
Use this form to document and review patient identification practices for quality and compliance.
Audit Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Auditor Name
*
First Name
Last Name
Department or Location
*
Patient Record Reference (non-governmental ID)
*
Patient First Name
*
Patient Last Name
*
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Type or Encounter Context
*
Please Select
Inpatient
Outpatient
Emergency
Day Surgery
Other
Identification Method(s) Used
*
Patient verbal confirmation
ID wristband
Photo ID (non-government)
Medical record label
Electronic health record
Other
Identification Matching Status
*
All identifiers matched correctly
Partial match
Mismatch
Discrepancy Details (if any)
Corrective Action Taken
Audit Outcome / Notes
Submit Audit
Should be Empty: