A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?
A) Determining the degree to which standards of care are met by reviewing patients' health records
B) Realizing that care not documented in patients' health records still qualifies as care provided
C) Basing reimbursement upon the diagnosis-related groups documented in patients' records
D) Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

Question

Quizplus · Accepted Answer

The auditing and monitoring of patients' health records involve nurses periodically auditing records to determine the degree to which standards of care are met and identifying areas needing improvement and staff development. The mistakes in documentation that commonly result in malpractice include failing to record nursing actions; this is the aspect of legal documentation. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Data analysis contributes to evidence-based nursing practice and quality health care.

A Nurse Is Auditing and Monitoring Patients' Health Records