Auditing nursing content in patient records

Abstract

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.

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

“…Depending on whether the resident met the inclusion criteria for PUs and/or MNA® scores of less than 17, the resident records were audited with two or three data collection forms. When auditing records for completeness the presence or absence of data is checked and the record content is assessed [24], that is if record data coheres with guidelines or recommendations based on best available knowledge. In this study we only assessed content in the records that met the inclusion criteria that is those records that held documentation indicating PUs or malnutrition.…”

“…When auditing records for comprehensiveness the coherence of the different phases of the nursing process is assessed [24] to ensure that data on patients' status, interventions and outcomes can be traced in the records. An instrument for determining the comprehensiveness in nursing documentation (CIND) [37] was used.…”

“…Health records should describe relevant and necessary information about residents and their health care [23]. The assessment of completeness in nursing documentation includes the presence or absence of essential resident data for nursing care, such as nursing assessments, interventions and outcome evaluations [24]. The evaluation of documentation comprehensiveness includes assessments of the relationships between the essential elements of the nursing process, including assessment, diagnosis, intervention and outcome [24].…”

“…The assessment of completeness in nursing documentation includes the presence or absence of essential resident data for nursing care, such as nursing assessments, interventions and outcome evaluations [24]. The evaluation of documentation comprehensiveness includes assessments of the relationships between the essential elements of the nursing process, including assessment, diagnosis, intervention and outcome [24]. Studies have shown a lack of accuracy and quality in nursing documentation in hospital settings [25,26] and a lack of accuracy in nursing documentation in nursing home settings [21,27].…”

Effects of nursing care planning tools on nurses’ and residents’ quality of life in long-term care facilities: A literature review

“…[13] Furthermore, there are several intervention studies that have investigated the effects of electronic care plans on these parameters. However, less is known about the effects of NCP tools on the course of everyday life in a nursing home.…”