The wider implications of an audit of care plan documentation

• This article describes how the results of an audit of district nursing care plan documentation have been used to inform practice development in a community trust. • The principle aim of the audit was to discover whether the evaluation of patient care was being adequately recorded in nursing care plans. • To establish this, four commonly occurring areas of district nursing work were selected and an ideal assessment of care developed from the available evidence. The areas were: the management of leg ulceration, bath care, pressure area care and catheter care. • Data capture forms were developed to record whether the features of an ideal assessment of these four areas of care were reflected in the written evaluation of that care. • The results of the audit demonstrated that the evaluation of care was often inadequately recorded, which reflected poor written documentation of the initial nursing assessment. • The implications of the findings of the audit for practice development in the four areas of care are discussed. © 1999 Blackwell Science Ltd.