The Buckinghamshire nursing record audit tool: a unique approach to documentation

A project to examine the quality of manual nursing documentation using an action research approach, prior to the introduction of a computerized system is described. The findings showed that there was a general lack of understanding about care planning. There was therefore a need to find an audit tool which could identify and develop nurses' knowledge of documentation as well as identifying the strengths and weaknesses of existing documentation. A literature review revealed Phaneuf's audit tool, but this proved difficult to use. Two nurse teachers agreed to develop their own documentation audit tool, based on the UKCC document on record keeping, which identifies criteria for effective documentation. A tool was developed which adopts a facilitative educational approach enabling the practitioner to audit and learn simultaneously. Much interest is being shown by other areas, and the questions are worded so that it could be used in a variety of settings.