A quality assurance intervention for auditing of nursing records in maternity units in a private healthcare facility
Date
2019
Authors
Fletcher, Lesley
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Abstract
Background
Global recognition has been awarded to the pivotal role played by good nursing records in the continuity and quality of patient care. In spite of this, and also a global phenomenon, studies report that nursing records do not meet expected standards.
Methodology
This mixed methodology study was completed in four phases. Phase 1 was quantitative involving an audit of patient records in two maternity units in a private healthcare organisation. Phases 2, 3 and 4 were qualitative and culminated in the development of a record audit tool designed to measure the quality of nursing care in a maternity unit. The record audit tool was based on information garnered through focus group discussions with nurses practising in the units, opinion by three different expert groups on elements and content to be included in the tool and the clinical utility of the record audit tool.
Results
The audit tool currently in use measures the completion of nursing activities and actions but does not measure quality of care. The audit tool that was developed during this study aimed to address this deficit. Factors other than knowledge and skill influence recordkeeping practices by nurses.
Conclusion
The audit tool that was developed was considered by the experts to be useful in measuring clinical judgment, person-centred care and adherence to the principles of good recordkeeping. Implementation of the tool will further advance the quality of care in the private healthcare facility.
Description
Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand in fulfillment of the requirements for the degree of Master of Science in Nursing
Johannesburg, June 2019
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Citation
Fletcher, Lesley Ann (2019) 2 A quality assurance intervention for auditing of nursing records in maternity units in a Private Healthcare facility, , University of the Witwatersrand, Johannesburg, <http://hdl.handle.net/10539/27987>