A nursing care monitoring and evaluation system: making it work in differentiated practice

This article describes the evolution of a chart audit tool that became an integral part of a nursing care monitoring and evaluation system at two healthcare agencies in South Dakota. These agencies, an acute care hospital and a federal healthcare agency, continue to use the audit tool for multiple purposes within their institutions. The initial design of the tool had two objectives: to measure objectively the quality and effectiveness of patient care provided by the nursing staff and to educate nurses about expectations of their roles as case managers or case associates. The tool has been revised and continues to be modified to fit needs within hospital, ambulatory care, and community based care settings, to meet program standards for accreditation, and other purposes within each agency.