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IMPROVING NURSING DOCUMENTATION
  1. Laura McMullen and
  2. Sue Gale
  1. East and North Herts NHS Trust, Northwood, England

    Abstract

    Background Audits in 2008 and 2009 show documentation was incomplete in 50% and 57% of cases: below an ideal standard of 91–100%. Omissions were due to poor utility by nurses and unsuitable pro-forma design, (duplication, lack of clarity, haphazard) and time consuming when transcribing to additional sheets at discharge. Nurses re-designed their pages which redressed problems highlighted and facilitated its use at discharge to community Health Care Professionals (HCPs). The resultant pro-forma was audited.

    Aim To ascertain completion of the new documentation compared with previous audits, confirm its use to community HCPs, and identify areas for improvement.

    Method The documentation was audited retrospectively using a copy of the pro-forma as the audit tool. Analysis was RAG rated: RED less than 70% completed, least acceptable, actions required. AMBER 70% – 90% completed, acceptable but scope for improvement. GREEN 91% – 100% completed, ideal standard.

    Results 15 sets of notes were audited (65% of one month's admissions). Data were collected on pages completed by nurses, which totalled 117 fields. Overall, 74% of the fields achieved either GREEN or AMBER status with the remaining 26% in the RED. Information commonly omitted related to community services, such as was the patient registered as ‘palliative’ with their out-of-hours GP provider, community HCP's contact details, and care planning post discharge. Data missing on admission included; co-morbidities, metastasises, contact numbers and expected discharge date. Results for tests/investigations were not documented in most cases. Each patient's community HCPs were sent a copy on discharge.

    Conclusion Significant improvements made using the new documentation; 26% in the RED compared with 100% in both pervious audits. Patient information is more succinct, de-duplicated, streamlined, and comprehensive enough to use at discharge to community HCPs; a survey of the latter underway. Nurses encouraged, and are, more diligent in recording information. Community information pending further review.

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