Authors (including presenting author) :
LUI WM, WONG MK
Affiliation :
Department of Medicine and Geriatrics, United Christian Hospital
Introduction :
Routine placement of indwelling bladder catheters should not be performed in acute stroke patients (American Heart Association & American Stroke Association, 2018). Whenever a catheter is inserted, an accurate and complete nursing documentation is then vital to provide evidence of care, ensure continuity of care (Nursing Council of Hong Kong, 2010), and inform clinical decision on evaluating patient’s care.
Objectives :
The aim of this program was to enhance nursing documentation on retention of urine [ROU] in the Acute Stroke Unit by using a standardized label template. The objectives were: 1. to standardize nursing documentation on ROU; 2. to develop a pre-designed label template for complete documentation; and 3. to reduce paperwork for nurses.
Methodology :
Items of nursing documentation on ROU were drafted and a label template was designed. Peer review comprising a ward manager, a nursing officer and an advanced practice nurse was held to explore various issues, e.g., clarity and readability of the documentation, and accessibility and user friendliness of the template. A pre (Jan to Mar 2018) and post (Feb to Apr 2018) intervention study design was performed to evaluate the impact of the label template on the completeness of nursing documentation about the ROU condition. Patient records were retrospectively checked for items of nursing documentation for ROU. These items were categorized into Focus Charting as below: DATA: Reason for residual urine [RU] check/ unable to self void/ no urine output DATA/ ACTION: RU volume/ checking method (e.g., bladder scan) ACTION: Inform doctor/ doctor’s name/ insert foley catheter RESPONSE: First catheterize volume/ send urine for culture
Result & Outcome :
A total of 39 documentations on urinary retention were checked from January to April 2018, of which 27 were fully handwritten and 12 were label template documentations. One handwritten documentation was excluded because it was done by nurse of patient’s previous admitted ward before transfer (N=38). Three cases (7.9%) with foley catheter inserted were found with no nursing documentation in patient’s Kardex in the pre-intervention period. Compared to those handwritten documentation (68.4%), the label template (31.6%) has shown significant improvement in completing the following items: Checking method of RU (p=0.000, χ2 test), Inform doctor (p=0.036, Fisher’s exact test) and Doctor’s name (p=0.000, χ2 test), First catheterize volume (p=0.022, Fisher’s exact test) and Send urine for culture (p=0.000, χ2 test). The label template appears to be effective in enhancing nursing documentation on ROU in terms of completeness.
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