| Popis: |
Current state: According to Act No. 372/2011 Coll., On health services, it is the duty of every health service provider to implement an internal control system. The purpose of internal audits is to identify deviations from recommended procedures and arrange for their correction. The aim of this research was to find out the opinions of general nurses and internal auditors on the influence of internal audits on the quality of provided nursing care and to evaluate the completeness and complexity of keeping nursing documentation. Methodology: The design of empirical research consisted of quantitative-qualitative procedures, the technique of content analysis of selected internal regulations, semi-structured interviews and secondary analysis of medical documentation (internal audit). The qualitative part of the research involved five general nurses working at the Department of internal medicine of a selected hospital in the South Bohemian region and five internal auditors within the same hospital. A content analysis of three internal regulations was performed. In the quantitative part of the research, 285 closed nursing documentation files were audited. Results: The research confirmed that internal audits of nursing documentation statistically significantly increase the accuracy of nursing care records. Repeated audits of nursing documentation have improved documentation management in the areas of identification of patient ID forms, standard procedure for correcting records, assessment of the risk of pressure ulcers, record of education about invasive entry, proposal of preventive measures to minimize the risk of falls and record of non-administration of drugs. Nurses and auditors evaluate internal audit as a suitable tool for maintaining and improving the quality of nursing care. Conclusion: Based on the identified shortcomings in the management of nursing documentation, we recommend the hospital management to increase the frequency of internal audits, identify the root causes of errors in the documentation management and arrange for their correction. Last but not least, we recommend to organize professional seminars on the issue. |
