Nursing audit as a method for developing nursing care and ensuring patient safety

Abstract

Nursing documentation is crucial to high quality, good and safe nursing care. According to earlier studies nursing documentation varies and the nursing classifications used in electronic patient records (EPR) is not yet stable internationally nor nationally. Legislation on patient records varies between countries, but they should contain accurate, high quality information for assessing, planning and delivering care. A unified national model for documenting patient care would improve information flow, management between multidisciplinary care teams and patient safety. Nursing documentation quality, accuracy and development needs can be monitored through an auditing instrument developed for the national documentation model. The results of the auditing process in one university hospital suggest that the national nursing documentation model fulfills nurses' expectations of electronic tools, facilitating their important documentation duty. This paper discusses the importance of auditing nursing documentation and especially of giving feedback after the implementation of a new means of documentation, to monitor the progress of documentation and further improve nursing documentation.

Figure 1.

Results of the audits of CCU nursing documentation in spring 2010, autumn 2010 and spring 2011.

Figure 2.

Results of the audits of KUS nursing documentation audits in 2010 and 2011.