Authors (including presenting author) :
Choi WM(1), Yuen ML(1), Chan KL(1), Ip WY(1), Luk YW(1)
Affiliation :
(1)Department of Paediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital
Introduction :
Nursing Documentation in patient’s clinical notes is the integral part of legal accountability of nurses. It serves a communication channel between health care professionals for monitoring patients' condition by nurses who take care of patient 24 hours a day. In 2017-2018, our department launched a continuous quality improvement program with guidance for proactive mechanism for increase its quality.
Objectives :
1. To furnish legal evidence of the process of HAHO Nursing Standard for Patient Care. 2. To align nursing documentation model among nurses in the department. 3. To provide feedback and recommend strategies for continuous improvement in nursing documentation.
Methodology :
Baseline data was obtained by retrospective audit of patients’ nursing records against a standard checklist from March to September 2017. The checklist consists of 19 questionnaires related to nursing assessment, care plan, nursing intervention and evaluation. 12 convenient samples were taken in each paediatric ward. The audit period was from admission and not less than 72 hours of hospital stay. Auditors were trained and bore no direct responsibility of patient care and documentation of the area they audited. Then 3 identical sharing sessions on knowledge and skill on nursing documentation based on the data gathered from the baseline audit and its improvement strategies were held for department nurses. Second audit with the same criteria and setting was held after nurses had consolidated the skill and knowledge for further 2 months after the sharing sessions.
Result & Outcome :
The overall compliance in baseline audit was 90 %, with 79% compliance on documenting patients’ problem of illness, response to medication and doctors’ prescription. Some nurses were unclear to the concept of nursing model, hence certain patients’ condition or response to therapy entries were omitted. However, after sharing sessions held for department nurses focusing on how to use nursing care model to guide them on documentation, overall compliance rate was improved from 90% to 97% with significant improvement from 79% to 94 % in the previous fair areas. Conclusions: Training is important to align the standard of practice. Remedy the existing weakness of nurses and offer similar training for new joint nurses will sustain same standard practice, and the culture would then be developed in a long run. Recommendations: 1. Periodic audit on nursing documentation by using the same set of questionnaires every 1-2 years. 2. Incorporate the training material into orientation program for all new joint nurses of paediatric department.
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