The single document with a comment section would contain both the new and old documentation would include.
- Qualitative audits examine the level of documentation by examining consistency in charting, adherence to rules, standards, and interpretations, as well as adherence to clinical practice guidelines.
- The main instrument for medical audit is a quantitative analysis of medical data, which is used to evaluate treatment team performance, improve executive operations in hospitals, and determine the effectiveness of hospital policies.
- Patient records must be scrupulously kept up to date by nurses. The Board of Registered Nursing and the Board of Vocational Nursing and Psychiatric Technicians sometimes exploit poor record keeping to cast doubt on a nurse's competence during disciplinary procedures.
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