NI 2012 (2012). 2012 Jun 23;2012:301. eCollection 2012.

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

NI 2012 : 11th International Congress on Nursing Informatics, June 23-27, 2012, Montreal, Canada. International Congress in Nursing Informatics (11th : 2012 : Montreal, Quebec)

Minna Mykkänen, Kaija Saranto, Merja Miettinen

PMID: 24199107 PMCID: PMC3799087

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.

References

1. Stud Health Technol Inform. 2006;122:540-1 - PubMed
2. Scand J Caring Sci. 2003 Sep;17(3):278-84 - PubMed
3. J Nurs Adm. 2010 Dec;40(12):509-14 - PubMed
4. Scand J Caring Sci. 2002 Mar;16(1):34-42 - PubMed
5. Comput Nurs. 1998 May-Jun;16(3):157-61 - PubMed
6. Int J Med Inform. 2008 May;77(5):291-304 - PubMed
7. Scand J Caring Sci. 2004 Sep;18(3):310-7 - PubMed
8. J Am Med Inform Assoc. 1994 Nov-Dec;1(6):421-7 - PubMed
9. J Adv Nurs. 2009 Mar;65(3):464-76 - PubMed
10. Int J Clin Monit Comput. 1989 Jul;6(3):173-9 - PubMed
11. J Gerontol Nurs. 2002 Sep;28(9):14-23 - PubMed
12. J Adv Nurs. 1996 Jul;24(1):98-103 - PubMed
13. Comput Nurs. 1992 Jan-Feb;10(1):19-24 - PubMed
14. J Adv Nurs. 2010 Jun;66(6):1388-400 - PubMed
15. Methods Inf Med. 2001 May;40(2):61-8 - PubMed
16. Int J Med Inform. 2010 Aug;79(8):554-64 - PubMed
17. J Nurs Manag. 2007 Sep;15(6):634-42 - PubMed
18. J Adv Nurs. 2004 Aug;47(3):329-39 - PubMed
19. J Med Syst. 2007 Aug;31(4):274-82 - PubMed
20. Comput Nurs. 2001 Mar-Apr;19(2):56-65; quiz 66-8 - PubMed

Publication Types

• Journal Article