Nursing audit as a method for developing nursing care and ensuring patient safety

Area of Science:

• Nursing Informatics
• Healthcare Management
• Patient Safety

Background:

• Nursing documentation is vital for high-quality, safe patient care.
• Current nursing documentation practices vary, with unstable nursing classifications in electronic patient records (EPRs) nationally and internationally.
• Varying legislation on patient records necessitates accurate, high-quality information for comprehensive patient assessment, planning, and care delivery.

Purpose of the Study:

• To evaluate the effectiveness of a national nursing documentation model in improving information flow, multidisciplinary team collaboration, and patient safety.
• To assess the usability and impact of an auditing instrument designed to monitor nursing documentation quality within a national model.
• To highlight the importance of auditing and feedback in refining documentation processes.

Main Methods:

• Development and implementation of a national nursing documentation model.
• Utilization of an auditing instrument to assess documentation quality and nurses' expectations of electronic tools.
• Analysis of auditing results from a university hospital setting.

Main Results:

• The national nursing documentation model appears to meet nurses' expectations for electronic documentation tools.
• The auditing process suggests the model facilitates nurses' documentation duties.
• The study indicates that auditing and feedback are effective in monitoring and improving nursing documentation.

Conclusions:

• A unified national model for nursing documentation can enhance interdisciplinary communication and patient safety.
• Auditing nursing documentation, coupled with feedback, is crucial for continuous quality improvement.
• The findings support the successful implementation of the national model in a university hospital setting, fulfilling nurses' needs for efficient electronic documentation.