Surgical Site Infection Prevention Audit

This template audits the core SSI prevention bundle elements around a single surgical case. It captures audit details, antibiotic prophylaxis timing, normothermia management, hair removal practices, perioperative glucose control, and surgical site readiness. It is designed to verify both what was done and what was documented in the source record.

It is typically used by perioperative quality staff, infection preventionists, nurse managers, surgical services leaders, or a designated auditor. A competent person familiar with the facility’s perioperative protocols should complete it so findings are consistent and actionable. It also works well for peer review or service-line spot checks.

Most facilities use it on a routine cadence such as weekly, monthly, or by case sampling, depending on volume and risk. It is also useful after a process change, a bundle rollout, or a rise in surgical site infection findings. The right cadence is the one that gives you enough cases to see patterns without turning the audit into a paperwork exercise.

It aligns with common perioperative quality and infection prevention expectations rather than one single rule set. Facilities often use it alongside Joint Commission expectations, CDC SSI prevention guidance, AORN practices, and internal policies. If your organization has a formal bundle or protocol, this template should mirror that local standard.

Common misses include antibiotic administration outside the facility window, missing incision-time documentation for comparison, and no redosing record for long cases. It also frequently surfaces absent temperature documentation, inappropriate razor hair removal, and glucose values that were not followed by protocol-based action. Skin prep issues often involve the wrong agent, inadequate drying time, or poor site readiness before incision.

Yes. You can tailor the antibiotic window, temperature target, glucose target, and skin prep agent to match your facility policy or specialty service. Many organizations also add service-specific fields for orthopedics, obstetrics, ambulatory surgery, or outpatient procedures. Keep the observable audit items intact so results remain comparable across cases.

An ad hoc review usually depends on whoever is looking at the chart and may miss the same issues from case to case. This template standardizes the questions, the evidence to review, and the sequence of the audit. That makes trends easier to track, repeat findings easier to escalate, and corrective actions easier to verify.

Review the anesthesia record, operative note, medication administration record, perioperative nursing documentation, temperature flowsheets, glucose results, and any pre-op checklist or skin prep documentation. If your facility uses separate pre-op, intra-op, and PACU records, include all relevant sources. The audit should identify which records were reviewed so findings can be traced back to the evidence.