NURSING MANAGEMENT: CONTROLING NURSING MANAGEMENT: CONTROLING
NURSING AUDITS Prepared by: Marjorie Ming MPH, RN (2007-08) 2
NURSING AUDITS NURSING AUDITS Definition of terms 1. Audit: a
formal examination of accounts. 2. Nursing Audit: an examination of
the patients records/charts to determine the quality of care he/she
received during a specified time. 3. Clinical audit: a quality
improvement process that seeks to improve patient care and outcomes
through systematic review of care against explicit criteria and the
implementation of change. 3 NURSING AUDITS NURSING AUDITS AIM: The
aim of this teaching session is to enable participants to develop
appreciation for the nursing audit and its value in assuring
delivery of quality patient care. OBJECTIVES: 1.Define relevant
terms e.g. audit, nursing audit, clinical audit, quality assurance.
2.Explain the purpose of the nursing audit. 3.Demonstrate knowledge
& skill in conducting nursing care audits in health care
facilities. 4.Utilize the audit to ensure high standards of nursing
care. 4 NURSING AUDITS NURSING AUDITS Definitions contd.: 4.
Quality Assurance: describes all activities related to
establishing, maintaining & assuring high quality care for
patients which includes assessment of patient care & correction
of problems. (Decker, 1985, p. 20) 5 NURSING AUDITS NURSING AUDITS
The Purpose of Nursing Audits a) To determine the quality of care
patients & or clients received at the health care facility.
Usually done retrospectively. b) To discover deficiencies or
omissions in the planning & delivery of nursing care. c) To
help nurses realize that their professional responsibilities go
beyond the mere following of doctors orders. d) Help nurses gain
increased awareness of their responsibility & accountability
for nursing decisions & actions. 6 NURSING AUDITS NURSING
AUDITS The Auditing Process Quality assurance auditing can be
voluntary or mandatory in order to meet standards set by
professional organizations and or state respect. Standards of
nursing care must be considered at all times. Care that does not
meet minimum standards jeopardizes the institutions accreditation
and the caregivers professional license. Inappropriate nursing care
can also be detrimental to patient safety. 7 NURSING AUDITS NURSING
AUDITS The Auditing Process contd. A periodic review of all record
& report forms is necessary for accurate evaluation based on
the information they contain. a) The patients chart may need to be
revised b) Departmental directives e.g. policies, procedures &
job description, need to be carefully studied. c) Staff compliance
with these directives is important for the safety & comfort of
patients & from a legal point of view. d) They also help to
determine the efficiency of the patient care unit. 8 NURSING AUDITS
NURSING AUDITS Conducting the Audit: 1.Chart Review a sampling
(percentage) of patient records is made from the total number of
records containing the criteria being reviewed. E.g. a specific
condition treated over a set period, to determine documentation of
care that meets criteria. 2.Patient care review a sampling of
records of currently hospitalized, recently discharged or deceased
patients may be reviewed to evaluate whether generalized criteria
are being met. 9 NURSING AUDITS NURSING AUDITS Conducting the
Audit: 1.Nursing care plans of randomly selected patients may also
be reviewed by observation or patient interview to verify that
routine procedures & rules are followed. The Results of the
Audit: .Must be analyzed to identify specific deficiencies. .Plans
to correct deficiencies should be made & implemented. 10
NURSING AUDITS NURSING AUDITS The Results of the Audit contd.:
Special in-service training programmes may be necessary to develop
or revise charting forms or nursing procedures. Periodic
re-evaluations should be conducted to ensure the resolution of
identified problems. The data collected should be analyzed at local
or institution-wide nursing care sites & solution identified
& implemented accordingly. 11 NURSING AUDITS: SAMPLE CRITERIA
FOR EVALUATION OF NURSING CARE PLAN NURSING AUDITS: SAMPLE CRITERIA
FOR EVALUATION OF NURSING CARE PLAN CRITERION MET NOT MET
EXCEPTIONS 1. Discharge goal is identified in writing 2. Primary
nurses signature located in appropriate box Exception: No primary
nurse 3. Nursing Diagnosis identified on nursing care plan
Exception: No problem at this time is written in nursing Care plan
4. Expected outcome is identified for each problem. 12 NURSING
AUDITS NURSING AUDITS Staff Nurses Responsibilities Each staff
nurse is responsible for the administration of quality nursing care
for patients assigned to him/her Documentation of the plan of care
& the care given are vitally important The nurse cant say but I
did it when faced with lack of documentation Remember! If it wasnt
charted, it wasnt done! NURSING AUDITS NURSING AUDITS DISCUSSION
QUESTIONS AND ANSWERS 13
