How to Write Up a Medical Audit
Health care is one of the most important issues facing our nation, yet the standard of care received in private practices, hospitals and long-term care facilities can often be substandard. This is why medical audits are so important. They play a pivotal role in meeting and exceeding health care standards by evaluating the current level of care and setting goals that will help to improve it.
- Difficulty:
- Moderately Challenging
Instructions
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Determine the reason for the audit. The determination process involves gathering input from workers, patients and patients' families. Before concentrating on a specific area that needs improvement, you must first know what areas your facility is weak in. Once you have this information, you can concentrate on the most important areas of care that require improvement.
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Collect available data and evidence to support the problems mentioned. Go through health records, nurses' notes and care plans for the patients. This will give you a better idea of where you are currently at and help you better focus on specific problems needing immediate attention.
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Focus on specific problem. If you are writing an audit for a private practice, one problem might be the amount of time a patient has to wait to be seen. If you are working for a hospital, you might focus on the amount of time it takes to answer a call light (the light above the door indicating a patient needs assistance). If the standards set for this is within 2 minutes and patients say it takes the staff 5 minutes to reach them, then you need to concentrate on ways for the staff to get to the patient quicker. If you work in a nursing home and find that incontinent patients are not being changed promptly, causing rashes or skin breakdown, you will focus on what can be done to avoid these unnecessary health problems.
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Set your desired standards. Ask the staff members what they think are acceptable standards. If it's the private practice, the staff may suggest spacing appointments out so that the patients are seen in a more reasonable time frame. For the hospital, the staff may suggest improving teamwork so that they are all working together to meet the patients' needs. Many times in health care, the main reason for patient neglect is the unwillingness of the staff to care for patients they are not assigned to. In the nursing home, a suggestion may be to begin the patient on a toileting schedule to cut down on the amount of accidents they have. Unfortunately in nursing homes, many patients are incontinent when they are capable of being toileted, even through the use of bedpans.
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Write the plan for improvement. After you have discussed the problems and possible solutions with your staff, write out a plan describing which improvements need to be made and a reasonable resolution for the problems identified. It helps to take into consideration the input of the direct care staff and incorporate some of their ideas into the plan of action. This will put them on the offense and motivate them to make the necessary changes by feeling as though their opinions count.
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Reveal the plan and discuss it with your workers. Begin to set goals to improve the standards of care. Discuss short-term and long-term solutions you have decided upon. The short term will have a definite effect on the long term, so set your goals within a reasonable time frame. If anyone feels a goal is unobtainable, they will not reach for it at all. Also set a time for re-evaluation. This will help in determining if the changes made have been effective and beneficial for the patients.
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Write your conclusion--a short and concise closing that summarizes the findings and the solutions that have been decided upon. Once you have completed this, save the audit so you can compare your next audit to it. It will help in determining which improvements have taken place and which areas still require attention from the health care team.
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