Auditing nursing content in patient records

• The objective of this paper is twofold: (a) to explore different approaches in reviewing records based on a literature review of studies of audits of patient records and (b) to apply these approaches on a sample of records to illuminate consequences of their application.The method used was a literature review of papers on recording of nursing care (n=56). Based on our findings, an audit of a stratified sample of records (n=298) from Swedish community health care and nursing homes was performed, applying the different approaches for auditing previously described in the literature.The review showed that audits of patient records were performed using four different approaches with varying aims. The focus of the four approaches can be described as formal structure, process comprehensiveness, knowledge-based and concordance with actual care. The results of this study suggest that audits of patient records should not be solely limited to encompass the formal structure of recording. To avoid a superficial picture or a false sense of high quality and to obtain a more complete and reliable portrait of the quality of recording, we suggest the process comprehensiveness approach in combination with a critical review of the knowledge base for the assessment, diagnosis and interventions of patient records.

Ämnesord

MEDICIN OCH HÄLSOVETENSKAP  -- Hälsovetenskap -- Omvårdnad (hsv//swe)

MEDICAL AND HEALTH SCIENCES  -- Health Sciences -- Nursing (hsv//eng)

Nyckelord

medical records

audits

nursing

Caring sciences

Vårdvetenskap

Publikations- och innehållstyp

ref (ämneskategori)

art (ämneskategori)