Date of Award
Evidence-Based Project Report
Doctor of Nursing Practice (DNP)
Julie A. Koch
Nationwide, nurses must withstand growing patient assignments and increased workloads. The consistency between nursing documentation and technical nursing interventions performed indicates that registered nurses provide much more care than they record. This incongruence has the potential to impact patient safety, but also has significant financial implications, since reimbursement is linked to documented services. The purpose of this EBP project was to implement a multifaceted reminder intervention (including a 10-minute PowerPoint and visual reminder) in an IMCU setting to assist the nursing staff (n = 38) in completing the HAPU documentation components. John Kotter’s Eight-Stage Process and the Iowa Model of EBP were used to guide this project. Retrospective HAPU audit scores from May, June and July 2015 were compared to audit scores from the intervention implementation months of September, October, and November 2015. Statistically signification improvements (p = .05) were found in ‘documentation of Braden scale on admission and every shift’ (p = .000) and ‘wound preventions supplies in room and in use with documentation’ (p = .002). Statistically significant decreases were also noted in ‘full body assessments on admissions and transfers’ (p = .000) and ‘ear protectors applied and documented’ (p = .000). Because there is limited published data regarding strategies to enhance nursing documentation, the results of this EBP project will add to the current literature and highlights the need for further intervention. Furthermore, changes could to be made to current electronic health record systems to meet the workflow requirements of nurses.
White, Meredith A., "The Effect of a Multifaceted Reminder Intervention on Nursing Documentation Completeness" (2016). Evidence-Based Practice Project Reports. 88.