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To provide feedback on documentation compliance, nurses in Orthopedic Services at Sacred Heart Medical Center in Spokane, WA, are given a sheet that shows them the areas in which they need improvement each time charts are audited. The feedback sheet follows the chart audit and has preprinted information and reminders, says Kris Becker, RN, MHA, director of Orthopedic Services. Areas covered include completion of the advance directive sheet, patient history, adult interdisciplinary data record, and plan of care with concerns, interventions, and expected outcomes listed.
When patient education assessments are not completed, that point is checked on the feedback sheet. The feedback tool reminds nurses that assessment covers a patient’s learning needs, preferences, and barriers to learning, and that all three sections need to be assessed.
"If their documentation did not include response to the pain management intervention, the feedback tool gives them a hint on ways to do that," says Becker. Incomplete documentation of pain management covers several issues that can be checked during a chart audit, such as: