A health care agency is applying for accreditation and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include:
A) Evidence of home care and nursing follow-up for six weeks following discharge
B) Self-reflection from nursing and other care providers about the quality of their care
C) Evidence that nurses have set goals for improving their future practice
D) Evidence that nursing interventions have been evaluated in terms of the client's response
D
Feedback:
The medical record serves multiple purposes, including a role in accreditation. Accreditors look for evidence of evaluation following interventions. The medical record is not the correct venue for nurses' self-reflection or personal goal-setting. Many clients do not require community-based follow up after they have been discharged.
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