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A comprehensive audit of nursing record keeping practice.
Paul Griffiths1, Samantha Debbage, Alison Smith
1Clinical Effectiveness Unit, Sheffield Teaching Hospitals NHS Foundation Trust.
British Journal of Nursing (Mark Allen Publishing)
|December 13, 2007
Summary
Regular clinical audits improve nursing record keeping for safer patient care. This study at Sheffield Teaching Hospital NHS Foundation Trust showed real improvements through audit, recommendations, and stakeholder involvement.
Area of Science:
- Healthcare Quality Improvement
- Clinical Audit
- Nursing Practice
Background:
- Effective patient care relies on high-quality record keeping.
- Clinical audits are crucial for maintaining and improving record-keeping standards.
- Previous assessments highlighted the need for enhanced nursing documentation.
Purpose of the Study:
- To conduct an audit and re-audit of nursing record keeping at Sheffield Teaching Hospital NHS Foundation Trust.
- To assess the impact of clinical audit on the quality of nursing records.
- To identify key factors for successful, ongoing record-keeping improvement initiatives.
Main Methods:
- A prospective audit and re-audit of nursing records was performed.
- Data collection focused on specific quality indicators of record keeping.
- Recommendations and action plans were developed based on audit findings.
Main Results:
- The audit demonstrated significant improvements in nursing record-keeping quality between 2005 and 2006.
- Implementation of recommendations and action plans led to measurable enhancements.
- Stakeholder involvement and senior nurse support were critical success factors.
Conclusions:
- Regular clinical audit is an effective tool for improving nursing record-keeping quality.
- A structured approach involving recommendations, action plans, and stakeholder engagement drives sustained improvement.
- The findings support the integration of audit data into local and organizational quality improvement strategies.
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