Auditing nursing content in patient records

The objective of this paper is twofold: (a) to explore different approaches in reviewing records based on a literature review of studies of audits of patient records and (b) to apply these approaches on a sample of records to illuminate consequences of their application. The method used was a literature review of papers on recording of nursing c are (n = 56). Based on our findings, an audit of a stratified sample of rec ords (n = 298) from Swedish community health care and nursing homes was per formed applying the different approaches for auditing previously described in the literature. The review showed that audits of patient records were performed using four different approaches with varying aims. The focus of the four approaches ca n be described as formal structure, process comprehensiveness, knowledge-ba sed and concordance with actual care. The results of this study suggest tha t audits of patient records should not be solely limited to encompass the f ormal structure of recording. To avoid a superficial picture or a false sen se of high quality and to obtain a more complete and reliable portrait of t he quality of recording, we suggest the process comprehensiveness approach in combination with a critical review of the knowledge base for the assessm ent, diagnosis and interventions of patient records.