Griffiths Paul, Debbage Samantha, Smith Alison
Clinical Effectiveness Unit, Sheffield Teaching Hospitals NHS Foundation Trust.
Br J Nurs. 2007;16(21):1324-7. doi: 10.12968/bjon.2007.16.21.27718.
Good quality record keeping is essential to safe and effective patient care. To ensure that high standards of record keeping are maintained, regular clinical audit should be undertaken. This article describes an audit and re-audit of nursing record keeping at Sheffield Teaching Hospital NHS Foundation Trust. The article demonstrates improving audit data in 2005 and 2006 and describes how audit and the resulting recommendations and action plans can result in real improvements in the quality of record keeping. The keys to success in this ongoing audit programme are identified as stakeholder involvement, support from the senior nurses in the organization and the use of the data for both local and trust-wide purposes.
高质量的记录保存对于安全有效的患者护理至关重要。为确保维持高标准的记录保存，应定期进行临床审计。本文描述了对谢菲尔德教学医院国民保健服务信托基金护理记录保存的一次审计及重新审计。文章展示了2005年和2006年审计数据的改善情况，并描述了审计以及由此产生的建议和行动计划如何能够切实提高记录保存的质量。在这个持续进行的审计项目中，成功的关键被确定为利益相关者的参与、组织中高级护士的支持以及将数据用于本地和整个信托机构的目的。
