Audits in the Field of Nursing, Both

¶ … Audits

In the field of nursing, both qualitative and quantitative data are useful and needed. The qualitative approach comes much from the patient and/or stakeholders. How does the patient "feel," what are some not quantittiative things one notices. Often, though, in charting a patient, a medical professional is able to quantify some of the qualitative data (e.g. complexion pale or wan; skin temperature, palor, attention span, etc.). The quantitative data are data that can be easily measured and work in tandem to provide a way to make a cogent diagnosis for the patient. Qualitative data is also part of the nurse's ability to make judgments about the quality and morality of situations, indeed, taking the principles of nursing ethics (beneficence, autonomy, etc.), many of those decision types are qualitative based. Some of this is, of course, related to secondary data sets from other research studies outside the purvue of patient-care, and aligns with a nurse's ability to improve their technique and understand research from other areas.Medical records verify notes over time, recording observations, the administration of drugs and therapies, orders from the doctor, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records on an ongoing basis is central to modern health care and is typically part of the requirements of licensing and certification (Information, 2011).

Chart Audits - Because charting information is so vital, both for patient health and appropriate, proper medical care, it is essential to have a procedure in place for charting audits. In a given week, a practice might see hundreds of patients, and no one can remember complex test results and data for that many people on a regular basis. Chart audits are a way to examin medical records (electronic or hard copy) to determine what the current procedure is and find ways of improving. There are four main purposes of the chart audit:

Required Measurments -- Within the modern mangaged care environment, the HEDIS (Health Plan Employer Data and Information Set) is widely used as a performance measurement. Chart audits are part of the collection of data for this set of requirements.

Administrative Requirements -- Federal, and many State, regulations require records documentation to justify coded charges and bills. Audits measure compliance.

Research -- Medical records contain a great deal of information that is useful to researchers in numerous fields. Without access to accurate data, no research could come close to locating and using such wide-ranging data.

Quality of Care -- Without a way to measure quality of care, it cannot be improved. Audits find holes in procedures, or ways in which medical functions can be improved (Chart Audits, 2005).

Outline - Conducting a Chart Audit- Chart audit procedures may be remembered by using a simple mnemonic: Too many patients stress the care system adversely.

1. Select a TOPIC

2. Identify MEASURES

3. Identify patient POPULATION

4. Determine SAMPLE size

5. Create audit TOOLS

6. COLLECT data

7. SUMMARIZE results

8. ANALYZE and apply results (Chart Audits).