| Course | HI230 Quality Assurance and Statistics in Health Information 1 |
|---|---|
| Unit | Unit 7 |
| Paper type | Records audit |
| Length | About 930 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | BS in Health Information Management |
| Updated | October 2026 |
Free sample paper for HI230 Unit 7
Four Criteria Written Down Before the First Chart Was Opened: A Unit 7 Records Audit of Thirty Adult Medical Discharges Measuring Allergy Status, Fall Risk Timing, Discharge Reconciliation and New-Medication Teaching Against a Ninety Percent Threshold
[Student Name]
Purdue University Global
HI230: Quality Assurance and Statistics in Health Information 1
Unit 7 Records Audit
[Instructor Name]
[Date]
The hospital, its policy thresholds and every record are composite; the audit method and the sources cited are real.
Purpose
The audit asks one question: do the records of adult medical inpatients show four safety tasks completed and documented as hospital policy requires? It is a documentation audit. It measures what the record shows, and a task done but never recorded counts as not met, since the record is the only evidence a later reader, a surveyor or a court will have (42 C.F.R. § 482.24, 2024).
Criteria, Dated Before Review
The criteria below were written and signed off by the health information manager and the medical unit's nurse manager on the Monday before the first record was pulled.
1. Allergy status. Met when an allergy entry, including "no known allergies," is recorded before the first medication dose. Source: medication management policy. Not applicable: none.
2. Fall risk assessment. Met when a completed fall risk assessment carries a time no later than eight hours after the patient's arrival on the unit. Source: fall prevention policy. Not applicable: none.
3. Discharge medication reconciliation. Met when the reconciliation is completed and signed by the discharging prescriber. Source: medical staff rules. Not applicable: deaths.
4. Education on new medications. Met when teaching on each medication started during the stay is documented before discharge. Source: patient education policy. Not applicable: records with no new medication.
The threshold for every criterion is 90 percent, the figure the policies name.
Sample
The eligible population was the 390 adult discharges from the two medical units between April 1 and June 30, excluding transfers to other hospitals. A systematic sample took every thirteenth discharge from the list after a random start between 1 and 13, which gave 30 records spread evenly across the quarter. No deaths fell in the sample. Thirty records suit a course audit and a first look, but they give rates with wide margins. A rate of 63.3 percent from 30 records has a 95 percent confidence interval running from about 46 to 78 percent, so the audit can say that fall risk timing falls short of 90 percent with confidence, but it cannot say whether the true figure is 55 or 70.
Method
Two reviewers, a health information technician and a nurse from the quality department, abstracted each record into a one-page tool listing the four criteria with met, not met and not applicable boxes and space for the time stamps used. Five records chosen at random were then abstracted again by the other reviewer without seeing the first result. The two reviewers agreed on 19 of the 20 criterion judgments, and the one disagreement, an allergy entry made eleven minutes after the first dose, was settled by the written criterion as not met.
Results
Each compliance rate is the number of records meeting the criterion divided by the number of records to which it applies, multiplied by 100, the same structure as any other proportion reported in hospital statistics (Horton, 2017).
1. Allergy status before the first dose: 27 of 30, 90.0 percent. Meets threshold.
2. Fall risk assessment within eight hours: 19 of 30, 63.3 percent. Short by 26.7 points.
3. Discharge reconciliation completed and signed: 25 of 30, 83.3 percent. Short by 6.7 points.
4. New-medication teaching documented: 20 of 26 applicable records, 76.9 percent. Short by 13.1 points. Four records were excluded because no new medication was started.
One criterion met its threshold, three fell short, and the widest gap was a task nurses complete on almost every patient, just late.
Findings
Ranked by distance from the threshold, the gaps are fall risk timing, then new-medication teaching, then reconciliation. The eleven fall risk misses were examined further. In all eleven an assessment was eventually recorded, at a median of about 14 hours after arrival, so the task was being done, but late. Nine of the eleven patients had arrived on the unit from the emergency department between 11 p.m. and 7 a.m., when admitting nurses on the medical units carried full assignments and the admission database was often deferred to day shift. Late screening matters because many inpatient falls happen early in a stay, and the point of the assessment is to start prevention before the first night. The evidence on fall risk tools is mixed; one review of inpatient studies concluded that none of the published scales predicted falls reliably across settings, which is why hospital programs pair a screen with routine prevention for everyone rather than relying on the score alone (Oliver et al., 2004). A screen recorded the next afternoon, however accurate, cannot guide the night that has already passed. The teaching gap clustered in anticoagulants and new insulin orders. The reconciliation misses were all weekend discharges with the reconciliation started but unsigned.
Recommendation
The fall risk timing gap is handed forward for improvement work because it is the largest, it follows a clear pattern, and it touches the patients most at risk on their first night. The teaching and reconciliation findings go to the unit's education council and the hospitalist group with the results above. The audit should be repeated on a fresh sample of 30 once a change is in place.
References
42 C.F.R. § 482.24 (2024). https://www.ecfr.gov/current/title-42/section-482.24
Horton, L. A. (2017). Calculating and reporting healthcare statistics (5th ed.). AHIMA Press.
Oliver, D., Daly, F., Martin, F. C., & McMurdo, M. E. T. (2004). Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age and Ageing, 33(2), 122-130. https://doi.org/10.1093/ageing/afh017
The Purdue Global HI230 Unit 7 instructions
Unit 7 typically asks you to plan and report a small documentation audit. Prompts commonly specify the record type and a sample size, then ask you to state the criteria, cite where each comes from, describe how records were selected and reviewed, and report a compliance rate for each criterion. Many sections set a threshold, often 90 percent, and expect each rate to be compared with it. You will probably need to handle records where a criterion does not apply and remove them from that criterion's denominator. A findings section usually ranks the gaps and identifies the one to take forward for improvement. Some instructors also want a note on reviewer agreement or on how much a small sample can show. Write the criteria in checkable terms so that two reviewers would reach the same answer from the same chart.
Inside the HI230 Unit 7 example
The audit opens with a one-sentence purpose and a note that it measures documentation, not care. The four criteria follow as a numbered list, each with what counts as met, its policy source and when it does not apply, dated before any record was pulled. The sample section explains the systematic selection and gives the confidence interval around the worst rate, which a margin note flags. Method describes two reviewers, the abstraction tool and a blind re-review of five records with 19 of 20 judgments agreeing. Results list each criterion's rate against the threshold, with four records excluded from the teaching criterion. Findings rank the three gaps, look inside the eleven fall risk misses for a pattern and cite research on fall risk tools. A recommendation hands the worst gap forward and sets a repeat audit.
Reading the HI230 Unit 7 grading rubric
Audit rubrics in HI 230 weigh method as heavily as results. Points go to criteria that are specific, sourced and fixed before review, and to a sample whose population and selection are described clearly. Accurate compliance rates with correct denominators, including not applicable exclusions, earn the next block of credit. Graders often reward a comparison of every rate with its threshold and a candid statement of what thirty records can support. Findings that rank the gaps and explain the largest one with evidence from the records score higher than a bare results table. A brief note on reviewer agreement shows care in method and usually earns credit. Presentation points cover a logical order, clear tables or lists, and APA 7 citations for the standards behind each criterion and any research used.
HI230 Unit 7 help: mistakes that cost points
The most damaging mistake is writing criteria after reading the charts, which lets the reviewer's impressions shape the standard. Fix them first and date them. Another is vague wording such as completed promptly, which two reviewers will read differently; give a time limit. Students also leave not applicable records in the denominator, lowering the rate unfairly, or report rates without the threshold they are measured against. A sample described only as thirty charts, with no population or method, invites doubt about every figure that follows. Keep the record itself as the evidence, so a task done but not documented counts as not met. Our team can build an audit around the criteria and record type your section uses if you send the prompt. Finally, look for a pattern inside the misses before you write the findings.
Get an HI230 Unit 7 example written to your instructions
Audit assignments differ in who sets the criteria, so say whether your Unit 7 prompt supplies them or leaves them to the writer, and send the instructions and rubric. The criteria table, sample plan and results come back in 24-48h, using composite or aggregate figures only. Your first sample will not be billed. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
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HI230 Unit 7 questions, answered
How many records should the audit sample?
Whatever the prompt specifies. Absent a figure, enough records to make each rate meaningful without pretending to precision. The example reviews thirty and says plainly that a figure from thirty records carries a wide margin, which suits a course audit and would not suit a board report. Describing the population and the selection method matters more than the size itself.
Where do the criteria come from?
From a written standard: medical staff rules, hospital policy, an accreditation expectation or a published measure. The example cites a source beside each criterion, because a criterion with no origin is only the reviewer's preference. If your prompt supplies criteria, use them as written; if it asks you to build them, name the standard each one comes from.
What does not applicable mean in a records audit?
A record the criterion does not fit, such as an education criterion for new medications when no new medication was started. Those records leave the denominator for that criterion only. The example shows the four it excluded and reports the education rate over the twenty-six that remained, so a grader can see the exclusion was a rule, not a convenience.
Where can I find a free HI230 Unit 7 sample paper?
The finished Unit 7 audit is posted on this page, covering four criteria, thirty records, a 90 percent threshold and the fall risk timing gap traced to overnight admissions.
How do you calculate a compliance rate in a records audit?
Count the records that meet the criterion, divide by the records the criterion applies to, and multiply by 100. Records where the criterion does not fit leave that denominator.