• Contemp Nurse · Jan 2015

    Designing a medical records review tool: an instructional guide.

    • Tracy McConnell-Henry, Simon Cooper, Ruth Endacott, Joanne Porter, Karen Missen, and Louise Sparks.
    • a School of Nursing and Midwifery , Monash University , Berwick Campus, 100 Clyde Road Berwick 3806 , Australia.
    • Contemp Nurse. 2015 Jan 1; 50 (1): 72-9.

    BackgroundMedical Records Reviews (MRR) are commonly used in research and quality activities in health care, however, there is a paucity of literature offering a step by step guide to devising a reliable, user-friendly tool.AimThis instructional paper focuses on the stages used to design and implement successful MRR using examples from two reviews in Australian rural hospitals investigating the responses of Registered Nurses to patient deterioration, and guided by time series principals.MethodsThe MRR were conducted in two rural hospitals in conjunction with a simulation learning intervention where nurses rehearsed clinical management of a deteriorating patient. A six-step template is presented to guide practitioners on how to design and use a MRR tool.ConclusionWhen well-planned and appropriately used, MRR provides an excellent means for examining patient outcomes in addition to safety and quality of care.

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