Stenvig T E, Karpiuk K
Community Health Services, Aberdeen Area Indian Health Service, SD.
Nurs Forum. 1991;26(1):27-34. doi: 10.1111/j.1744-6198.1991.tb00872.x.
This article describes the evolution of a chart audit tool that became an integral part of a nursing care monitoring and evaluation system at two healthcare agencies in South Dakota. These agencies, an acute care hospital and a federal healthcare agency, continue to use the audit tool for multiple purposes within their institutions. The initial design of the tool had two objectives: to measure objectively the quality and effectiveness of patient care provided by the nursing staff and to educate nurses about expectations of their roles as case managers or case associates. The tool has been revised and continues to be modified to fit needs within hospital, ambulatory care, and community based care settings, to meet program standards for accreditation, and other purposes within each agency.
本文介绍了一种图表审核工具的演变过程，该工具已成为南达科他州两家医疗机构护理监测与评估系统的一个组成部分。这两家机构，一家急症护理医院和一家联邦医疗机构，在其机构内继续将该审核工具用于多种目的。该工具的初始设计有两个目标：客观衡量护理人员提供的患者护理的质量和有效性，以及让护士了解对其作为病例管理员或病例助理角色的期望。该工具已经过修订，并持续进行修改，以适应医院、门诊护理和社区护理环境中的需求，满足认证的项目标准以及各机构内的其他目的。
