Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients' health records?

Question

a. The nurse determines the degree to which standards of care are met by reviewing patients' health records.
b. The nurse realizes that care not documented in patients' health records still qualifies as care provided.
c. The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients' records.
d. The nurse compares data in patients' records to determine whether a new treatment had better outcomes than the standard treatment.

Answer 1

ANS: A
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, "care not documented is care not provided." 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. Analysis of data from research contributes to evidence-based nursing practice and quality health care.