Date of Doctor of Nursing Practice Project Completion
Summer 8-9-2024
Faculty Advisor
Dr. Kala Christopherson
Abstract
PURPOSE
Accurate nurses’ notes are important for patient safety, complete nursing care, coordination and continuity of care, communication, reimbursement, and regulatory requirements. The purpose of this quality improvement project was to use standardized training to improve the percentage of nurses’ notes that pass auditing by 50%. The project also aimed at reducing by 50% the number of notes returned by reviewers to nurses because they were incomplete.
BACKGROUND
The project was implemented in a home healthcare agency with an average of 200 patients and 30 field nurses. Current nurses’ notes returned as incomplete were 30%.
METHODOLOGY
A training program was developed from the nursing process and the Nursing and Midwifery Audit Content Tool (NMCAT). Using a standardized audit tool and basing documentation on the nursing process along with staff training have the potential to improve the quality of nursing documentation. Two months pre-implementation, 100 de-identified nurses’ notes were randomly selected and audited for a baseline. The nursing staff were trained on the NMCAT and then 100 de-identified notes were randomly selected and audited two months post-implementation for comparison.
RESULTS
The training was attended by 25 nurses. The project demonstrated a 53% improvement in returned notes which meant only 14% of notes were returned post-implementation compared to 30% pre-implementation. The mean difference of improvement in notes that passed the audit criteria was 17.2 (P = .001).
IMPLICATIONS
Auditing nurses’ notes with a validated audit tool and standardized training of nurses are sustainable nursing documentation improvement strategies.
Keywords
Nursing documentation, nurses’ notes, electronic health records, home healthcare, audit, standardized training, nursing documentation improvement, quality
Recommended Citation
Amponsah, Mavis, "Improving the Quality of Nursing Documentation Among Nurses in Home Healthcare" (2024). Doctor of Nursing Practice Final Project Abstract. 29.
https://digitalcommons.library.tmc.edu/dnp_abstract/29