PEER AUDITS OF ELECTRONIC MEDICAL RECORDS: STRATEGY FOR QUALITY PERFORMANCE

This project involved developing a medical record audit process within a shared learning environment, and evaluation of nurse learning and perceptions that enhance/hinder audit participation. Two tools were developed: an audit tool with metrics to determine changes in documentation quality, and a survey assessing learning/audit process perceptions. Fifteen Certified Nurse Midwives (CNMs) participated in the audit process, and completed perception surveys pre- and post-audit. Surveys assessed factors that potentially enhance or hinder the audit process in three domains: Learning, Reluctance, and Time. CNMs audited 3-5 randomly selected electronic medical records (EMRs) from another CNM to assess adequacy and placement for items related to prenatal care. After audits were complete, CNMs reviewed aggregate audit quality scores and discussed learnings from the audit experiences and methods to improve documentation. There was a significant decrease in perceptions of reluctance in audit participation (p < .001). Additionally, review of individual item scores showed that CNMs perceived that they had learned from the experience, valued the audit process in terms of potentially enhancing documentation of care, and felt the time spent for audits was worthwhile.. Results highlighted the need for adequate time to conduct audits. This study suggests that an audit process with a shared learning team approach may yield benefits of changes in perceptions about documentation quality.