Pediatric Family-Centered Rounds Documentation Audit

Audit pediatric rounding documentation to verify family presence, questions addressed, and plan-of-care teach-back were documented consistently.

Audit Scope and Encounter Details

• Audit date and chart/encounter identifier documented
• Patient location and service documented
• Rounding note or documentation source identified
• Encounter reviewed is a pediatric inpatient rounding event

Family Presence and Participation

• Family or caregiver presence documented
• Relationship of participating family member(s) documented
• Family participation level documented
• Interpreter use documented when needed
• Privacy and family-centered communication maintained during rounds

Questions, Concerns, and Teach-Back

• Family questions or concerns documented
• Responses to family questions documented
• Plan of care explained in family-friendly language
• Teach-back or confirmation of understanding documented

Plan of Care and Next Steps

• Assessment and plan documented clearly
• Next steps or pending tasks documented
• Discharge or follow-up considerations documented when applicable
• Documentation reflects shared decision-making when applicable

Documentation Quality and Compliance

• Documentation is timely relative to rounds
• No conflicting or ambiguous statements in the note
• Any deficiencies or non-conformances summarized