NURSING AUDIT

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NURSING AUDIT:

NURSING AUDIT Presented By: Mrs. Jenifer D’Souza Associate Professor LMCN, Mangalore

What is AUDIT ?:

What is AUDIT ? Audit is a review of the clinical records used to determine the presence or absence of pre determined criteria - Schmele (1980)

What is Nursing Audit?:

What is Nursing Audit? An assessment of the quality of clinical nursing --- Elison A method of evaluating quality of care through appraisal of the nursing process as it is reflected in the patient care records for discharged patients

In other words…..:

In other words….. An exercise to find out good nursing practices that are followed . i.e., it is a means by which nurses themselves can define standards from their point of view and describe the actual practise of nursing.

In Community………..:

In Community……….. Audit comprises of …….. a systematic review …… of a specified number of service records in a given period of time & the development and implementation of corrective measures when deficiencies in quality care are identified

Types of Audit:

Types of Audit Financial Audit Cost Audit Stationary Audit Medical audit Nursing/ Patient care audit

Concurrent Audit:

Concurrent Audit Open chart audit Done when client is receiving care in the health center, home etc

Retrospective Audit :

Retrospective Audit Closed chart audit After the client care is completed.

Purposes ::

Purposes : To evaluate the care provided To achieve desired quality care To achieve feasible quality care For better recording As a legal document Provides accountability of care It contributes to research.

Types of Auditors:

Types of Auditors Internal Audit External Audit Internal Audit External Audit

Internal Auditors:

Internal Auditors Nursing staff Done continuously Consists of abstracting and classifying clinical records and evaluating the quality of care for clients.

External Auditors:

External Auditors Medical administrators from ministry/ professional bodies/ other agencies. Periodically Done

Audit Committee:

Audit Committee Minimum 5 members Each member reviews not more than 10 records in about 15 minutes If less than 50 cases in a month, then all records be audited. More than 50 cases, then 10% of the cases may be selected

Slide 14:

SET STANDARD OBSERVE PRACTICE CAMPARE WITH STANDARDS IMPLEMENT CHANGE AUDIT CYCLE

Focus of Nursing Audit:

Focus of Nursing Audit Diagnosis e.g.. DM Diagnostic test. e.g. Blood smear collection Problem e.g. referrals, home visit. Process e.g. TPR, Dressing, Any procedures

Approaches to Audit:

Approaches to Audit Structure Audit Process audit Outcome Audit

Structure Audit:

Structure Audit Focusses on the nurses notes, based on the assumption that good nurses notes, reflected quality care. Today it involves the setting in which health care is provided– the organizational structure, physical set up, resources and equipment and qualification of the care giver.

Process Audit:

Process Audit Earlier(prior to 1964) evaluated whether a nurse performed her assigned duties Today, it involves : The Quality patient Care Scale The Phaneuf Nursing Audit

Outcome Audit:

Outcome Audit A retrospective audit. Compares with the standards that were set or outcome criteria

Audit Processing:

Audit Processing Audit done -------- submit a report to the chairman--------- conducts meeting--------- reviews the findings--------- prepares a report-------- and recommendations --------- submits for signature.

Phaneuf Nursing Audit Tool:

Phaneuf Nursing Audit Tool Application and execution of medical officers legal orders Observation of symptoms and reactions Supervision of the client Supervision of those participating in care Reporting and Recording Application and execution of nursing procedures and technique

Application & execution of MO Orders:

Application & execution of MO Orders Medical diagnosis and orders complete Prompt execution of the orders

Observation of Symptoms & Reactions :

Observation of Symptoms & Reactions Vital signs checking and recording Symptoms identified and promptly reported Any complications due to treatment

Supervision of the client and those participating in care:

Supervision of the client and those participating in care Safety of the client Security of the client Continuing assessment of client’s condition and capacity. Interaction with family & significant others Care taught to client, family Consideration of client’s physical, emotional capacity to learn.

Reporting and Recording:

Reporting and Recording Essential facts reported to client. Facts on which further care depended were recorded. Client & family alerted as to what to observe and report to physician. Continuity of care.

Application & Execution of Nursing Procedures and Techniques:

Application & Execution of Nursing Procedures and Techniques Administration of medications as per standing orders / MO orders Personal Care Nutrition and special diets Physical activity Rehabilitation & prevention of complications Procedures / techniques taught to the client.

AUDIT METHODOLOGY:

AUDIT METHODOLOGY Statistical method Mortality review committee method Random table method Scoring method On the spot method.

Concept of Nursing Audit:

Concept of Nursing Audit DEBIT ITEMS Death of client Complications due to neglect Infection at health center. Wrong treatment Incorrect information/ education. Inadequate care. CREDIT ITEMS Number of clients recovered Shorter duration of illness Good records Expansion of client knowledge Client acceptance of care.

Failure of Audit ::

Failure of Audit : Rejects standard use of the evaluation tool Lack of knowledge Fear of criticism Resistance on part of management Absence of client care records/ documents. Absence of standards.

Slide 30:

Thank you !!!