I.

INTRODUCTION: Nursing Audit

- It is a review of the patient record designed to identify, examine, or verify the performance of certain specified aspects of nursing care by using established criteria. It is also the process of collecting information from nursing reports and other documented evidence about patient care and assessing the quality of care by the use of quality assurance programmes. It is a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. - It incorporates the systematic and critical analysis by nurses, midwives and health visitors, in conjunction with other staff, of the planning, delivery and evaluation of nursing and midwifery care, in terms of their use of resources and the outcomes for patients/clients, and introduces appropriate change in response to that analysis (NHS ME, 1991 Framework for Audit for Nursing Services). - According to Elison "Nursing audit refers to assessment of the quality of clinical nursing". - According to GosterWalfer, Nursing Audit is an exercise to find out whether good nursing practices are followed and also the nursing audit is a means by which nurses they can define standards from their point of view and describe the actual practice of nursing. Purposes of Nursing Audit 1. Evaluating Nursing care given, 2. Achieves deserved and feasible quality of nursing care, 3. Stimulant to better records, 4. Focuses on care provided and not on care provider, 5. Contributes to research. In our nursing audit, we were tasked to do a nursing audit at PR Annex on July 31, 2013 at around 3:43pm of the same day. Nursing Audit (PR ANNEX) with Justification A. FORMAT 1.Nursing history is complete within 24 hours. The nursing history and most of the patients chart were completed in the ER in less than 24 hours before admission because nursing history is part of the documentation in the ER. ER nurses are properly trained to get the complete history of the patient before transfer to in-patient unit. 2. Attending physicians name is recorded.

 All the patients chart that were subjected to audit has recorded the names of the attending physician as evidenced on the admission summary report. Nurses, medical clerks and resident doctors determine the name of the attending doctor before transfer to unit. 3. Sheets arranged in proper sequence. All of the charts that were assessed were arranged in sequence according to SLU-HSH protocol from patients profile up to the present laboratory results because nurses were trained to follow such protocol. 4. Informed consent for admission/special procedure and treatments are signed by client and/or SO. Informed consent was accomplished and signed by the patients who are able and their significant others who have authority because nurses see to it that an informed consent is properly accomplished prior to admission. According to the AJOB Primary Research (2010), Informed consent is regarded as a pillar of medical ethics. To improve current practices, patients should receive more information about the risks and benefits of surgery as well as any available alternatives. Information about the expected length of hospital stay, post-discharge follow-up, and the cost of surgery should also be provided to patients. To improve the perceived quality of the informed consent process, more emphasis should be placed on ensuring that patients receive the requested information in a manner they can comprehend. Redesigning consent forms may be an important step in improving the patients experience of the informed consent process. 5. Patients full name recorded in every sheet. Among the 6 charts that were subjected to audit, there were 2 charts that fall under the YES category and 4 patients chart were under the NO category because the common findings was that the middle name of the patients were not recorded in every shift. Nurses tend to be lazy to complete the name of the patient in every sheet. 6. Charting in correct ink color per shift utilized. All of the NOD and SNs on duty in every shift from 7-3 up to 11-7 use the correct color of the ink in documenting all the pertinent data in every shift because it is strongly implemented in this institution. 7. No erasures. Errors drawn through and identified. Among the 6 charts that were subjected to audit, 5 patients chart has an erasure ranging from superimposition up to not using the proper way of admitting anyones wrong entry by putting an ME an attaching their signature because it is a rampant malpractice among RNs in the hospital.

 In the Indian Journal of Urology (2009), It is very important for the treating doctor to properly document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This will be the only way for the doctor to prove that the treatment was carried out properly. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues. Medical records form an important part of the management of a patient. Improper record keeping can result in declining medical claims. 8. Correct abbreviations used Doctors and nurses in the area are aware and expected to use the accepted and correct abbreviations in documentation in accordance to certain international group. It is noted in physicians order and nurses notes that is why 5 charts fall under the YES category and only 1 is under the NO category. 9. Laboratory results attached according to dates. Among the 6 charts, 4 were under the YES category and only 2 were under the NO category because laboratory results were properly arranged according to sequence from the latest laboratory results. Nurses in the area are fully aware of the proper sequencing of sheets in patients chart. B. DOCTORS ORDERS 1. Doctors orders are legible, dated and signed. Most of the charts have doctors orders that are legible, dated, and signed (4 out of 6). This is probably because although the orders are dated and signed appropriately, the penmanship of the doctors is not legible at times. The style of their handwriting may sometimes cause the reader to have a hard time deciphering or comprehending their meaning. From the article by, Sokol, D. & Hettige, S. (2006), For members of the health care team, deciphering the notes can be a nuisance, sometimes requiring the assistance of colleagues and, if a signature is present and legible, a direct call to the author. From the patient's perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate doses which, in turn, can result in discomfort and death. Illegible handwriting in medical records can have adverse medico-legal implications. Stephens notes that few admissions look more damaging in testimony than physicians admitting they cannot read their own handwriting. 2. Medications are prescribed in generic. Half of the group observed that medications are prescribed in generic. Some doctors use the trade names of the drug being prescribed. Examples of these medications in their brand name include Ceelin and Growee. According to the study of Manojkumarsaurabh, et al. (2010), most doctors prefer to use generic name when making their prescriptions. Wherein Generic medicine and use of drugs in compliance with essential drug list were found in 2624 (69.8%) and 2620 (69.7%) of total drug prescribed.

3. Orders are carried out and signed within 1 hour. Most orders are not carried out and signed within 1 hour (4 out of 6). In one case, an order was carried out and signed 2 hours and 10 minutes after it was ordered, which was the longest interval observed by the group. It was also observed that the orders which were carried out late are those that were ordered during 3-11 or 11-7 shift, where there is no head nurse assigned, only an acting head nurse who also share with the staff nurses work. 4. Verbal orders are countersigned by physicians within 30 minutes. In most cases (5 out of 6), no verbal orders were given or noted. However, in one case, the order was given at 7:20am, and was signed at 7:25am, which is less than 30 minutes. The order was signed in less than 30 minutes possibly because the ward is an area of private rooms, where patients are usually given more attention. Furthermore, the staff nurses made sure to coordinate with the physicians in charge so they can ensure their signatures. This is supported by the study of Gommans, et al (2008), wherein it stated that Staff were educated about the risks of and restricted role for verbal orders. Documented incidents were highlighted and staff reminded of alternatives including faxing of charts or, in more recent years, use of the air tube system to send charts to and from medical staff working in other areas of the hospital. Verbal orders are now very uncommon (<1%). 5. Standing orders are signed within an hour. The group were not able to identify which orders in the Physicians notes were standing orders, hence they were not able to identify whether the standing orders were signed within an hour. 6. STAT orders are timed, carried out, charted, and signed within 15-20 minutes. Four of the group handled charts that didnt have STAT orders, while the remaining two said yes. In one case, the order was given 7:25am, and was timed, carried out, charted, and signed within 5 minutes. 7. Special procedure/referrals are accomplished and noted within the shift. Most of the charts handled implied that the special procedures are done within the shift (5 out of 6). This is probably due to the good collaboration between the departments in the hospital to achieve this procedures and referrals promptly. However, in one case, the accomplishment of the special procedures occurred beyond the shift when it was ordered. No reasons were indicated in the chart why this happened. C. NURSES NOTES 1. Nurses notes are complete, legible and relevant Most of the nurses notes are legible and relevant but are incomplete, such as the admitting notes, while some of the charting of registered nurses are short and with erasures. According to CMS Manual System (2009), all entries in the medical record must be legible. Orders, progress notes, nursing notes, or other entries in the medical record that

are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events. All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient; support the diagnosis/condition; justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers. 2. Notes are signed with the designation of nurse stated. In all charts that we handled, the name of the nurse is written after the charting and his/her signature is written above their names. According to CMS Manual System (2009), the authentication of medical record entries may include written signatures, initials, computer key, or other code. For authentication, in written or electronic form, a method must be established to identify the author. When rubber stamps or electronic authorizations are used for authentication, the hospital must have policies and procedures to ensure that such stamps or authorizations are used only by the individuals whose signature they represent. There shall be no delegation of stamps or authentication codes to another individual. 3. Assessment a. Idiosyncrasies to food, drugs, substance, etc., are communicated and documented. In all charts, the foods and drugs are properly documented and allergies to such are written down in the patients profile and/or on clerks and student nurses documentation. b. Religious beliefs/practices on food, treatment, drug, or blood administration noted. In most charts, the religion of the patient is written in the patients profile but the religious beliefs/practices on food, treatment, drug, or blood administration were not documented. c. General physical and mental condition noted. In most charts, the general physical and mental condition was assessed and noted by the Junior Intern, and also documented as a data (D) in the nurses notes. According to Scott R.W. (2006), the symptoms such as the use the persons own words, communication gestures, or non-verbal cues as much as possible. Also, your observations are very important since failure to document leaves gaps in the record that can be interpreted as neglect. And also, all the injuries, illnesses and unusual health situations until they are resolved. There should be entries in the nursing notes on a regular basis until the problem is no longer present. d. Unusual observations/critical conditions are documented. In most charts, the unusual observations/critical conditions are well documented in the nurses notes such as fever of 380C, bleeding, enlargement of abdomen, etc. According to Scott R.W. (2006), new symptoms/conditions should be documented in the nursing notes such as (a) abrasions, cuts, pressure marks, (b) falls and bumps, with or without apparent injury, (c) elevated temperature, (d) pressure ulcers including description and treatment until resolved, (e) rectal checks for constipation including findings and treatment, (f) seizures with complete description and treatment, if any, (g) possible adverse reactions to food or medicine, (h) refusal of meals or medications, (i) vomiting including type, amount, and treatment, (j) STAT medications including time order is received and time medication is given, (k) unusual behavior or condition of the

individual, (l) diarrhea or any change in bowel pattern, (m) any significant increase or decrease in weight, (n) changes or unusual difficulty in obtaining vital signs e. Patients problems identified/charted. In all charts, the patients problems were accurately identified and written down in the focus (F) of the nurses notes. 4. A nursing care plan exists There is no written nursing care plan in all the charts that we handled. According to Scott R.W. (2006), Documentation should reflect that a plan of care is developed based on nursing assessment and diagnostic reasoning 5. Nursing actions are documented. In all charts, the nursing actions are well documented in the actions (A) of the nurses notes. In another work, Karkkainen and Eriksson (2004) note that, although standardized forms of documentation can enhance concise and directed information, poorly designed forms may enhance document content but do little to support patient-centric care. The challenge is to design systems that are patient focused but also reap the benefits of standardization in terms of more accurate, precise, and up-to-date information transfer among all members of the interdisciplinary team. 6. Effectiveness of nursing actions noted. Most charts indicated that the nursing actions were effectively provided to the patients as seen in their response (R) that is written in the nurses notes. According to Scott R.W. (2006), when the problem is resolved, it should be documented. Also, response to medication or treatment should be documented since it has therapeutic actions and side effects. Also, Urquhart and Currell (2004) completed the most systematic and comprehensive review, examining the literature through 2004. They focus on nursing record systems as variations in the systems effect nursing practice and patient outcomes. 7. Teaching/discharge plans noted and copy given to patient or family. Most doesnt have the discharge plan yet since the patients are not yet discharged from the hospital. References: Shiva (2008, December 14). Nursing Audit. Retrieved August 8, 2013, from http://nursingparadise.blogspot.com/2008/12/nursing-audit.html Mutha, R., and Ameen, S. (2010, December 10). Nursing Audit. Retrieved August 8, 2013, from http://currentnursing.com/nursing_management/nursing_audit.html Sheikhtaheri, A. & Farzandipour, M. (2010). Factors Associated with Quality of Informed Consent in Patients Admitted for Surgery: An Iranian Study. AJOB Primary Research. DOI:10.1080/21507716.2010.528507. pages 9-16. Thomas, J.(2009). Medical records and issues in negligence. Indian Journal of Urology. doi: 10.4103/0970-1591.56208. Jul-Sep; 25(3): 384388. Sokol, D. & Hettige, S. (2006). Poor handwriting remains a significant problem in

medicine. J R Soc Med 2006 December;99(12):645-646 Gommans, J., McIntosh, P., Bee, S. and Allan, W. (2008):Improving the quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions, Internal Medicine Journal 38 243248 Manojkumarsaurabh, Jaykaran, Ashishkumaryadav, NareshJyoti (2010):Study of prescribing pattern and assessment of rational use of drugs in tertiary hospital, Rajasthan, Journal of Pharmacy Research 2010, 3(3),474-477 Karkkainen, O., Eriksson K. (2004) Structuring the documentation of nursing care on the basis of a theoretical process model. Scand J Caring Sci. 18:22936. Centers for Medicare & Medicaid Services (2009, June 5). Revised Appendix A, Interpretive Guidelines for Hospitals. Retrieved August 13, 2013, from http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R47SOMA.pdf Scott R.W.(2006). Legal Aspects of Documenting Patient Care for Rehabilitation Professionals (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.