where to start

PsychNurseWannaBe, BSN, RN · Mar 20, 2008

assignment question
The quality of record keeping in your nursing unit is poor, design a quality improvement programme for your nursing service to improve the quality of record keeping.
:stone

Well no one is really going to do your homework assignment for you. But I will tell you this. When doing anything assigned in nursing school, follow the nursing process. It is a great problem solving tool.

1. Assessment

2. Diagnosis

3. Planning

4. Intervention

5. Evaluation

So with your assignment... the first thing you must do is assess what is wrong with the record keeping to begin with before you can do anything else. Then move on through the nursing process, on step at a time. Whatever information you gather in the preceeding step will affect the steps to follow. So a thorough assessment needs to be done before anything else.

Good luck!

Daytonite, BSN, RN · Mar 20, 2008

I wasn't quite sure how to answer this when I saw the question last night. You definitely use the nursing process (the problem solving method) to guide you in how you go about working through the problem. That's what PsychNurseWannaBe has suggested you do. The nursing process is a common sense, or logical approach, to answering questions.

However, you also need some specific information about record retention and filing. I've been studying for a degree in Health Information Management and filing and medical record management is what that profession does in the United States. Unfortunately, I don't know how they file and store medical records in your country. This is something that I think you are going to have to find out in order to complete this assignment. One of the things I would recommend that you do is to go to a hospital nursing unit (if you can) and see and ask how they handle patient charts. I mean observe it very closely. Ask if the facility has a policy or special rules on how patient records are to be handled and stored, and if so, could you see them (here in the U.S. we have laws on how the records are to be kept). I would also go to your school library and see if there are any textbooks there on medical records and how they are handled. I would also look for any textbooks that are used by the workers who handle these records (unit clerks, secretaries, they may have a different job title than they do here in the United States), but somehow they are trained to handle these records. Collect all this information because you will need it to support the quality improvement programme for your nursing service to improve the quality of record keeping in this assignment of yours.

I was in quality improvement committees for years. What they do is

assess a specific current procedure
determine where steps of the procedure are not being followed as they are supposed to be followed and identify these as problems
design an improvement program (this is very similar to developing nursing interventions for a patient to treat his/her nursing problem)
put the improvement plan into action
do a reassessment of the procedure to evaluate if the new improvements to the procedure are yielding positive results (in this case, greatly improved record keeping)

Hope that helps give you an idea of how to approach this assignment. I would surmise that if the subject of medical records and documentation of what has been done for the patient approaches any kind of significance as it does here in the U.S. then there are probably professionals around to oversee the handling of patient records in your country too. At the least, a hospital or clinic will have some kind of rules about what goes into a patient chart, in what order, and where it is to be stored.