Chart Audit: Strategies to Improve Quality of Nursing Documentation

  title={Chart Audit: Strategies to Improve Quality of Nursing Documentation},
  author={Frankie W. H. Wong},
  journal={Journal for Nurses in Staff Development (JNSD)},
  • F. W. Wong
  • Published 1 March 2009
  • Medicine
  • Journal for Nurses in Staff Development (JNSD)
Nursing documentation is an essential component for professional practice and providing quality patient care. [] Key Method This project assessed nurses' documentation skills and consistency between prescribed care and care provided to patients. Strategies have now been implemented to improve nursing documentation and resolve issues that were identified during the chart audit.

An evaluative audit of the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland

This project evaluated a new palliative nursing documentation system and identified that utilizing a structured document promoted accurate recording of clinical information and limits inconsistent documentation.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review.

Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool.

The present study provides new audit solutions based on time-sampling approaches and focused evidence-based criteria for monitoring the quality of nursing documentation at a unit level or across health facilities to demonstrate compliance with quality standards.

Evaluation of registered nurses' knowledge and practice of documentation at a Jamaican hospital.

The study showed high levels of accurate documentation by nurses at a referral hospital in Western Jamaica and the nurses appeared to be familiar with the required documentation guidelines with policy manuals available on each ward.

The Development of Information Systems in Documentation Management of Critical Care Nursing

The research result shows that this software very useful because it shortens the time for preparing reports and enable nurses in documenting their nursing care easier and well documented.

Improving pain documentation with peer chart review

Background When face-to-face communication isn’t possible, healthcare team members rely largely upon the medical record for information about a patient’s clinical status.1 A vital part of the medical

The Effects of Structured Health Policy Education on Connecticut Registered Nurses' Clinical Documentation.

A statistically significant difference between pre and post education quality scores was found and improvement drivers of the post-education quality scores were identified in the subscales of ‘diagnosis as a process’ and ‘interventions’.

Preventing surgical site infections: Facilitators and barriers to nurses' adherence to clinical practice guidelines-A qualitative study.

There is a need to develop interventions to improve nurses' adherence to recommended CPGs including following aseptic technique principles, hand hygiene, documentation and patient education.

Effects of HIS-based intervention on patient education process and patient satisfaction with nurses' education

The ability to easily, completely, and quickly edit and record the provided education, eased the process of patient education and documentation.



Nursing documentation: a program to promote and sustain improvement.

The integration of peer auditing and continuing education enabled nurses to attain and maintain specific documentation standards and there was a statistically significant decrease in documentation errors.

Documenting patient education: a literature review.

  • F. Casey
  • Medicine
    Journal of continuing education in nursing
  • 1995
Administration and staff development can enhance nurses' efforts to document more effectively and forms and flowsheets detailing content and learner outcomes and tracking patients' progress can affect the quality of documentation.

Evaluation of nursing documentation of patient teaching.

  • Y. Porter
  • Medicine, Education
    Journal of continuing education in nursing
  • 1990
This study indicates that reinforcement in the form of a preprinted care plan combined with inservice education and audit increases documentation of patient education more than the use of the preprinted document alone.

Eliminating friendly fire. Successful nursing documentation strategies.

The authors highlight several of the strategies used by one nursing service department to eliminate barriers to adequate documentation.

Improving documentation using a nursing model

A number of issues debated among the participants in this study could be seen as organizational matters and lead to the important issue of multidisciplinary and organizational work when implementing innovations within nursing.

Review of nursing documentation in nursing home wards - changes after intervention for individualized care.

The RAI/MDS instrument seems to be a useful tool for the dynamic process in nursing care delivered and as a basis for documentation, which should communicate a patient's situation and progress.

The nursing role in preventing delay in patient discharge.

  • A. Macleod
  • Medicine
    Nursing standard (Royal College of Nursing (Great Britain) : 1987)
  • 2006
The common causes of delayed discharge are described and the importance of effective multidisciplinary team-working is emphasised through a review of a 'whole systems approach' to discharge.

Wound Documentation: Managing Risk

This continuing education activity is intended for physicians and nurses with an interest in better understanding and improving policies and procedures related to wound documentation.

Legal aspects of psychiatric nursing.

  • L. Barloon
  • Medicine, Psychology
    The Nursing clinics of North America
  • 2003

Resident documentation discrepancies in a neonatal intensive care unit.

Daily progress notes written by resident physicians in the neonatal intensive care unit often contain inaccurate, or omit pertinent, information, and alternative means or methods of documentation are warranted.