QUALITYASSURANCE
QUALITYASSURANCE
QUALITYASSURANCE
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Madhuri Shelke
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Principal, I.N.E.R,
Key Words
Quality assurance:
Quality assurance can be defined as “the promise or guarantee that certain standards of
excellence are being met in care delivered.”
Introduction:
Accountability for nursing practice has significant roots in the history of nursing. Florence
Nightingale, the founder of modern nursing, was one of the first to document the need for a
systematic approach for reviewing the quality of nursing care. She identified the need to
incorporate health data and statistics in quality assurance activities. The quality assurance for
Public Health Nursing is to provide specific standards, measurement tools and processes for
improving the quality of public health nursing practice. The extent to which the standards are
implemented is determined by those who govern the day-to- day activities of public health
programs.
Expect Excellence. Use a positive approach and expect to find excellence. The site visit
provides an opportunity to identify, acknowledge and/or share models of excellence,
which may benefit other public health practice settings.
Apply CQI Concepts. Quality Assurance/Quality Improvement is a process and a
journey. Where there are opportunities for improvement, be constructive when suggesting
alternative solutions.
Respect the Environment. Site visitors do not normally work at the site and need to be
mindful of the site’s policies and procedures, hours of operation, routines, wearing of
proper identification and professional attire, etc.
Focus on Established Standards. Site visits should be based on established standards.
Build the Partnership. Site visitors need to work side by side with staff from the site
throughout the site visit. This provides an opportunity to discuss and/or clarify all
findings in a collaborative manner.
1. Contents of a clinical record must meet all regulatory, accrediting and professional
organization standards. Common requirements specific to nursing documentation include, but are
not limited to:
a. The nursing assessment and care provided;
b. Informed consent for any/all procedures;
c. Teaching provided either to the client directly or to his/her family; and d. Response and
reaction to teaching.
2. Determine and assure adequate security measures for the entire documentation system,
electronic and/or paper.
3. Record the client's name on every page.
4. Record the date and time on all entries.
5. Sign every entry with full name and initials of professional and educational titles (e.g., RN,
APRN, FNP).
6. Entries by students, interns, and residents should indicate title (e.g., SN: Student Nurse)
and be countersigned by the licensed professional supervising their training.
7. Make sequential entries, only on approved forms and in approved locations on the client's
record.
8. Make all entries permanent. For handwritten entries, use only blue or black non-erasable ink.
Do not alter the character of a record with “white-out”, highlights, scratching or
their markings. Any change in character or altered look in any of the documentation should
never occur in a client’s medical record.
9. Do not attempt to erase, obliterate or “white-out” a handwritten error. If errors are made, write
"error" and initial/date the line.
10. Assure that entries are legible, with no blank spaces left on a line or in any area of
documentation. Draw a line through blank spaces to the end of a line, or use diagonal lines to
mark through an area. (In a lawsuit, an effective case may be made for a sloppy record to suggest
sloppy care).
11. Use only standard, approved or accepted list of abbreviations, acronyms, symbols and dose
designations as outlined in the current policy on standard abbreviations (See copies of policy and
standardized list in the current Public Health Nursing Policies and Practice Guidelines Manual).
12. Write entries specifically and completely, using objective data from one's own observation,
assessment and treatment of the client. Avoid language that is ambiguous, vague or speculative.
13. Make all entries promptly and within appropriate time periods, given the client's condition
and diagnosis.
14. Late entries or entries made at a day/time other than when care was provided should be
clearly indicated.
15. Write objectively and with extreme care when making entries that describe an adverse
episode and subsequent interventions.
16. Specify the client's approval when family members or non-healthcare professionals serve as
translators or when documenting informed consent (including signed consent forms).
17. Document all counselling and education given to the client. Be specific, including client's
reactions and responses.
18. Specify when a client fails to comply with recommended self-care regimen or refuses to
accept recommended diagnostics and/or treatment.
19. Record the date, time and content of all telephone communications. If messages are left for a
client, document the name/relationship of the person taking the message.
20. Assure that entries of verbal orders are signed by the order-giver within the time frame
established by organizational policy.
21. To assure continuity of care for clients, all clinical health information pertaining to an
individual client should be stored in one clinical record, which includes clinical data from any
single service, encounter, and/or program.
Conclusion:
The Community Health Nursing Quality Assurance (QA) provides consultation services to
achieve an effective health care delivery system for our County through conducting clinics and
programs. Community Health Nursing Quality Assurance is found in home health and health
maintenance organizations.
References:
1. Joseph, Eric D. and Webster, Nancy E, The Record that Serves and Protects, 1st ed., Care
Education Group, Inc., 1999.
2. Missouri State Health Department, "Documentation, General Documentation
Guidelines", www.health.state.mo.us/Publications/300-25.html.
3. Barry Herrin, J.D., telephone conversation, recorded by Argartha Russell, RN, MSA, CPHQ,
September 13, 2000.
4. ―Guidelines and Legal Principles for Clinical Record Documentation in Public Health
Nursing‖, Georgia Department of Community Health, Division of Public Health, Office of
Nursing, (DVD), 2008.
5. ―Principles for Documentation,‖ American Nursing Association, Silver Spring,
2005.