A quality assurance intervention for auditing of nursing records in maternity units in a private healthcare facility

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.