uu.seUppsala University Publications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Auditing nursing content in patient records
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences. (Centre for the Classification of Diseases in the Nordic Countries)
2001 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 15, no 2, 133-41 p.Article in journal (Refereed) Published
Abstract [en]

The objective of this paper is twofold: (a) to explore different approaches in reviewing records based on a literature review of studies of audits of patient records and (b) to apply these approaches on a sample of records to illuminate consequences of their application.

The method used was a literature review of papers on recording of nursing care (n=56). Based on our findings, an audit of a stratified sample of records (n=298) from Swedish community health care and nursing homes was performed, applying the different approaches for auditing previously described in the literature.

The review showed that audits of patient records were performed using four different approaches with varying aims. The focus of the four approaches can be described as formal structure, process comprehensiveness, knowledge-based and concordance with actual care. The results of this study suggest that audits of patient records should not be solely limited to encompass the formal structure of recording. To avoid a superficial picture or a false sense of high quality and to obtain a more complete and reliable portrait of the quality of recording, we suggest the process comprehensiveness approach in combination with a critical review of the knowledge base for the assessment, diagnosis and interventions of patient records.

Place, publisher, year, edition, pages
2001. Vol. 15, no 2, 133-41 p.
Keyword [en]
medical records, audits, nursing
National Category
Nursing
Identifiers
URN: urn:nbn:se:uu:diva-53591DOI: 10.1046/j.1471-6712.2001.00011.xISI: 000169059400003PubMedID: 12078626OAI: oai:DiVA.org:uu-53591DiVA: diva2:81501
Available from: 2008-10-17 Created: 2008-10-17 Last updated: 2017-12-04Bibliographically approved

Open Access in DiVA

No full text

Other links

Publisher's full textPubMed

Authority records BETA

Smedby, Björn

Search in DiVA

By author/editor
Smedby, Björn
By organisation
Department of Public Health and Caring Sciences
In the same journal
Scandinavian Journal of Caring Sciences
Nursing

Search outside of DiVA

GoogleGoogle Scholar

doi
pubmed
urn-nbn

Altmetric score

doi
pubmed
urn-nbn
Total: 394 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf