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What is Nursing Records Quality Audit Guide about?

This document presents a format for auditing the quality of nursing records in hospitalization. It contains 6 sections to be evaluated, which include patient identification, vital signs, fluids, assessments, medication sheet, and care plan. Aspects such as legibility, use of conventions, absence of cross-outs and corrections are reviewed. The auditor fills out a table with scores for each element and section, and at the end assigns an overall qualitative rating.

Author

ScribdTranslations

Language

EN