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Abstract: 

Screening involves nurses’ collection and review of information about the health of every person admitted to the facility and making nursing decisions about patients’ immediate needs for medical or mental health attention, ongoing treatment and protection from harm. It is a high risk, problem-prone aspect of correctional health care and should be regularly reviewed by the Quality Improvement Program and studied to identify opportunities to improve practices. This article uses a “chart audit” to examine the effectiveness of intake screening and shows how to use an audit to reinforce good practice and identify practices that reduce the effectiveness of screening and increase the likelihood that a serious medical or mental health condition will be overlooked.

Keywords: Chart audit; timely referrals; access to health records; active listening

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