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Auditing completion of nursing records as an outcome indicator for identifying patients at risk of developing
María López1, Mercedes Fernández-Castro2, Belén Martín-Gil3
1Nursing Faculty, University de Valladolid, Valladolid, Spain.
Aim:
To evaluate the completion of nursing records through scheduled audits to analyse risk outcome indicators.
Background:
Nursing records support clinical decision-making and encourage continuity of care, hence the importance of auditing their completion in order to take corrective action where necessary.
Method:
This was an observational descriptive study carried out from February to November 2020 with a sample of 1131 electronic health records belonging to patients admitted to COVID-19 hospital units during three observation periods: pre-pandemic, first wave, and second wave.
Results:
A significant reduction in nursing record completion rates was observed between pre-pandemic period and first and second waves: Braden scale 40.97%, 28.02%, and 30.99%; Downton scale: 43.74%, 22.34%, and 33.91%; Gijón scale: 40.12%, 26.23%, and 33.64% (p < 0.001). There was an increase in the number of records completed between the first and second waves following the measures adopted after the quality audit.
Conclusions:
The use of scheduled audits of nursing records as quality indicators facilitated the detection of areas for improvement, allowing timely corrective actions.
Implications For Nursing Management:
Support from nursing managers at health care facilities to implement quality assessment programmes encompassing audits of clinical record completion will encourage the adoption of measures for corrective action.
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