The wider implications of an audit of care plan documentation

This article describes how the results of an audit of district nursing care plan documentation have been used to inform practice development in a comm unity trust. The principle aim of the audit was to discover whether the evaluation of pa tient care was being adequately recorded in nursing care plans. To establish this, four commonly occurring areas of district nursing work w ere selected and an ideal assessment of care developed from the available e vidence. The areas were: the management of leg ulceration, bath care, press ure area care and catheter care. Data capture forms were developed to record whether the features of an idea l assessment of these four areas of care were reflected in the written eval uation of that care. The results of the audit demonstrated that the evaluation of care was often inadequately recorded, which reflected poor written documentation of the i nitial nursing assessment. The implications of the findings of the audit for practice development in t he four areas of care are discussed.