A comprehensive audit of nursing record keeping practice.
Good quality record keeping is essential to safe and effective patient care. To ensure that high standards of record keeping are maintained, regular clinical audit should be undertaken. This article describes an audit and re-audit of nursing record keeping at Sheffield Teaching Hospital NHS Foundation Trust. The article demonstrates improving audit data in 2005 and 2006 and describes how audit and the resulting recommendations and action plans can result in real improvements in the quality of record keeping. The keys to success in this ongoing audit programme are identified as stakeholder involvement, support from the senior nurses in the organization and the use of the data for both local and trust-wide purposes.
Griffiths
Paul
P
Clinical Effectiveness Unit, Sheffield Teaching Hospitals NHS Foundation Trust.
Debbage
Samantha
S
Smith
Alison
A
D019985:Benchmarking; D004282:Documentation / Q000592:standards* / Q000706:statistics & numerical data; D017598:Efficiency, Organizational; D004739:England; D005568:Forms and Records Control; D019983:Guideline Adherence; D017408:Guidelines as Topic; D007722:Health Knowledge, Attitudes, Practice; D006301:Health Services Needs and Demand; D006784:Hospitals, Teaching; D006801:Humans; D009731:Nursing Audit / Q000458:organization & administration*; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000592:standards* / Q000706:statistics & numerical data; D009741:Nursing Staff, Hospital / Q000193:education / Q000458:organization & administration / Q000523:psychology; D009936:Organizational Innovation; D019984:Quality Indicators, Health Care; D018570:Risk Assessment; D017751:Safety Management; D013222:State Medicine; D017749:Total Quality Management / Q000458:organization & administration