选定一个实习科别中最常见的诊断或健康问题.pptVIP

Guideline for Developing an Record Audit Tool Chang Gung University School of Nursing Adult Nurse Practitioner Program Tsui-Hsia Feng RN, MS, CRNP Purpose develop a record audit tool presenting both process and outcome audit criteria to be used by nurse practitioners in auditing records in clinical care settings. The tool must state the process and outcome criteria to be used in the audit of the record of a patient seen in a clinical care setting. The tool may be general or problem specific. 如 Audit tool for management of type 2 diabetes mellitus Audit tool for management of knee osteoarthritis with total knee replacement Audit tool for management of low back pain …. Rationale for selection of each criterion is to be stated briefly. Draft Due Date: 04/22/08 AUDIT TOOL FOR DM 2.doc Guideline for record audit tool development 選定一個實習科別中最常見的診斷或健康問題 注意: 不要選太艱深或太複雜不常見的問題 針對此診斷或問題的處理過程及成效評核標準進行最新文獻查證(evidence-based practice) 先依此設計成一流程圖或表(初稿) 然後依此寫成一個檢核表 經老師看過後，再到臨床找5個個案chart做record audit 這些cases 最好不是你的個案，且最好是要出院的個案 Guideline forrecord audit tool development The purpose of the audit is to determine the usefulness of the criteria in practice. The auditor will submit the record audit and a critique of the tool. The critique should address the elements that were useful and why, and suggestions for improving the utility of the audit tool. This audit tool and your findings will be submitted to your preceptor for review. Guideline for record audit tool development 　做完後，寫成報告 (due 06/17/08)，內容包括 Content (50%) Stated both process and outcome criteria Rationale supports criterion selection Format (15%) Overall appearance, style, presentation Correct grammar, spelling, punctuation Adequacy of references, bibliography Creativity Report on audit of 5 records (35%) Maximum 5 pages on this section Audit Tool Format Have these following content been performed and/or documented in the chart? (All item developed need to revie