You are on page 1of 5

Nursing audit is a detailed review of the patient record designed to identify, examine, or verify the performance of certain specified

aspects of nursing care by using established criteria. It is also the process of collecting information from nursing reports and other documented evidence about patient care and assessing the quality of care by the use of quality assurance programs. There are two types of nursing audit concurrent and retrospective. A concurrent nursing audit is performed during ongoing nursing care. While a retrospective nursing audit is performed after discharge from the care facility, using the patient's record. One of the first ever clinical audits was undertaken by Florence Nightingale during the Crimean War (1853 1855). Another famous figure, Ernest Codman (1869 1940), also advocated clinical audit by monitoring surgical outcomes. Both of them employed methods that highlight ways that can be used in the process of providing quality patient care. The first report of Nursing audit of the hospital was published in 1955. Nursing audit is done to evaluate nursing care given, achieve deserved and feasible quality of nursing care, stimulant to better records, focus on care provided and not on care provider, and contribute to research. A. Format Nursing history is complete within 24 hours. The history was taken on the same day the patient was admitted. The history is important because it provides pertinent data regarding how the patients condition developed and the interventions employed which can help in the development of a more effective plan of care. The physicians name was recorded on the appropriate pages on the patients chart. Recording the physicians name makes referral easier because other members of the health care team because they would know whom to alert when any untoward manifestations were observed on the patient. Proper sequence was followed. Doing so saves time and effort in looking for and recording of needed data. Consent was signed. Obtaining consent for admission or any special procedure protects the patient from any possible malpractice which may be committed during the course of treatment. Also, consent protects the institution and its personnel.

Patients full name was written on all pages of the chart. It ensures that the record belongs to the right patient. Correct ink was used for charting per shift. This is done to monitor the progress in the patients condition. Writings were improperly erased. Instead of drawing a line, white ink was used. Also, there were superimpositions in the doctors orders and progress notes. Since the chart is a legal document, it is used as a basis in case anything happens to the patient and improperly erasing some entries makes the entry doubtful. Correct abbreviations were used. Using of approved abbreviations prevents confusion among those delivering care to the patient. The laboratory results were not attached according to date. Proper sequence makes monitoring of patients condition easier. B. Doctors Orders Some of the doctors orders were not written legibly, not dated, but were all signed by the physician. Also, the orders for medications included the dosage and frequency of administration. If orders are not legible and not dated, it may not be understood well so it may not be properly executed, or the execution may take time because extra time will be used in reading the orders. All but one medication was prescribed in generic. Vestar was ordered instead of using trimetazidine. It was stated in RA 6675 that the use of generic terminology in prescription of drugs is encouraged. It is because the price is lower. The orders were carried out and signed within one hour. Proper timing and execution of orders ensures that the prescribed care was delivered to the patient. There were no verbal orders recorded in the patients chart. Nevertheless, countersigning of the physician makes certain that the order really came from the identified physician.

It cannot be determined whether the standing orders are signed within an hour since the order was not dated nor timed. Signing standing orders guarantees that the order was executed by the nurse on duty. There were no STAT orders in the patients chart. But failure of immediate execution of STAT orders may compromise patients condition. Referrals are accomplished and noted within the shift. Noting referrals are important since a doctor would not make any referrals if the patient does not need it. C. Nurses Notes Nurses notes were complete and relevant but some were illegible. It is a legal document where the problems identified during the shift and the interventions done were written so they have to be legible and complete. Notes were signed with designation of nurse stated. This should be done to know who is accountable in whatever happens to the patient. Idiosyncrasies to food and drugs were documented and communicated. This is important to prevent accidental occurrence of allergic reactions. No assessment was documented regarding the beliefs or practices of patient about food, treatment or other things. This should be done to prevent offense on the side of patient. Also, assessing these helps the patient to cooperate in the plan of care thus patient may feel empowered. General physical and mental condition was noted. Holistic assessment gives the nurse a better picture of patients condition thus appropriate care could be delivered. No unusual observations or critical conditions were documented. But this is important so that prompt action will be done and prevent further complications. Patients problems were identified and charted. This is to easily see the progress of the client and will serve as a basis for the continuity of care.

No nursing care plan was seen in any available document of the patient. A nursing care plan guides nurses in the delivery of care based on patients assessment findings. Nursing actions were documented. As was mentioned, anything that is not documented is not done. Effectiveness of nursing actions was noted. For example, the problem identified in one of the nurses notes was risk for infection and the documented response was the absence of fever during the shift. It is important to record the effectiveness of nursing actions because this will serve as a basis for modifications of the care plan to improve the patients well being. No teaching or discharge plans was seen in the chart since the patient is not for discharge yet. It is important to note these, to make sure that proper instructions were given to the patient and to ensure continuity of care even if the patient is at home promoting recuperation. Proper documentation is very important not only for the daily use in patients care but also its legal implications. As mentioned in the article The Importance of Accurate Documentation, the author was a witness in an ongoing hearing of a case involving a preoperative patient she took care of 5 years before the trial. Since it had been years, she had to rely on her documentation when she was questioned in court. Eventually, the judge commended her because her notes were clear and concise. Thereby, the author stressed the importance of proper documentation. Furthermore, another article Poor Records can Reflect Poor Practice reminded on the skill of proper documentation since there was a case involving it wherein the death of a baby was investigated and that the documents presented does not back up the midwife strongly. This is because her notes were incomplete and that there was improper keeping of the records. Since her records were incomplete, it was then viewed by the coroner who handled the case that inappropriate and inadequate care was rendered. Documentation should not only be the sole focus on the care of a patient but also the quality of care being given to them. Because though the documents are complete and properly kept, if the patients are not satisfied with the care they receive then the documents would be seen useless. A study published in 2011 entitled Quality of care from patients perspective: impact of the combination of person-related and external objective care conditions concluded that sex(women), age(older), psychological well-being, frequency of over-occupancy and the number

of RNs are important factors that must be emphasized if patients are to perceive the quality of care as high. As for another study, Changes in quality of life among newly diagnosed breast cancer patients in Taiwan, it found out that preoperative physical and psychological factors, as well as sense of self-efficacy for managing the cancer, are important factors for predicting changes in patients quality of life. So as nurses, we should assess these contributing factors so we will have an idea of the patients perception of the quality of care rendered to them. Also, if we assess these, appropriate interventions will be made so as to meet patients needs.