Audit Tools for Nursing Care Plans

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A nursing care plan outlines the specific actions a nurse and nursing facility should take for an individual requiring ongoing care and assistance. The developed and administered care plan is based on an individual's medical diagnosis. Care plans should be frequently updated based on the latest findings and research conducted by medical professionals and research institutions. The quality of an administered care plan has a direct impact on the time a patient requires care and their overall health.

The Nursing Audit

  • An audit involves the review and inspection of information from such sources as nursing reports and documentation. Nursing care plans may be reviewed while a client is receiving care and also retrospectively after care has been completed. One benefit of retrospective audits is to assure that a nursing facility is adhering to care plan procedures. Understand available audit tools to assure that nursing care plans are being monitored in the most effective way.

Process Model

  • According to the National Center for Biotechnology Information, audit tools should encompass a nursing process model that includes assessment, diagnosis and appropriate actions based on diagnosis, planned interventions, implementation of those interventions and evaluation of results. Interventions could include, for example, special care, patient education and drug handling.

Recordkeeping Quality Checklist

  • According to the National Center for Biotechnology Information, audit tools should encompass a nursing process model that includes assessment, diagnosis and appropriate actions based on diagnosis, planned interventions, implementation of those interventions and evaluation of results. Interventions could include, for example, special care, patient education and drug handling.

Care Audit Evaluation

  • Since the existence of high-quality patient records does not guarantee high-quality care, a care quality audit tool must also be used. Such a tool examines if the patient's condition is noted upon his arrival at a facility, if it is updated periodically and at discharge. A patient diagnosis should be examined by a third party to determine if the diagnosis is accurate and if the subsequent treatment is appropriate. Although each patient's situation is different, written guidelines should be available showing that types of treatment are appropriate for each condition.

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