Using record review as a quality improvement process.
A patient's record is a repository of personal data, the plan of care, and documentation of assessment and treatment. The record review process can facilitate a clinician's understanding about documentation standards and requirements as well as help to maintain a state-of-audit readiness of the record for regulatory and accrediting surveys.
Durkin
Nancy
N
Visiting Nurse Association of Greater Milford-Northbridge Area, 25 Birch Street, Building B, Milford, MA 01757, USA. NDurkin@milreg.org
D000068:Accreditation / Q000458:organization & administration; D003152:Community Health Nursing / Q000458:organization & administration; D004282:Documentation / Q000592:standards; D019983:Guideline Adherence / Q000592:standards; D006699:Home Care Services / Q000458:organization & administration; D006801:Humans; D008404:Massachusetts; D024802:Nurse's Role; D009730:Nursing Assessment / Q000458:organization & administration; D009731:Nursing Audit / Q000458:organization & administration*; D015403:Nursing Evaluation Research / Q000458:organization & administration; D009737:Nursing Records / Q000592:standards; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration; D010347:Patient Care Planning / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D017749:Total Quality Management / Q000458:organization & administration*