In an effort to establish controls, a new manager decides to spend one afternoon each week double-checking every chart his nursing care staff has completed for the previous week.  (a) In what ways is this attempt at control ineffective? (b) What would be examples of an internal and an external control the manager could set up to improve any problems with charting?

(a) This control attempt may not be effective for many reasons. It may not be enough time to check the charts every week for errors and catch them quickly. This approach, which focuses on correcting errors once they occur, is not proactive but reactive. This approach can lead to mistrust among employees and micromanagement, which could result in lower job satisfaction and productivity.

(b) An internal control that the manager could set up to improve problems with charting is to implement a peer review process, where nursing staff review each other’s charts on a regular basis to catch and correct errors. This is proactive, and it can reduce the likelihood of errors occurring. Implementing a chart audit tool such as a checklist, flowchart or checklist can standardize charting and help ensure all information is included.

An external control that the manager could set up is to work with the organization’s quality improvement department to develop and implement evidence-based charting guidelines and protocols. The manager can seek out external expertise to help make sure that charting practices are consistent with industry standards and best practice. The manager might consider installing a charting system that incorporates error-checking and alerts. This will help reduce manual review of charts as well as improve accuracy and timeliness in documentation.

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