The effect of quality assurance on flight nurse documentation

This study was developed to evaluate if a structured quality assurance program has an effect on nursing documentation. A randomized, retrospective audit of records was conducted from 1985 to 1989, and in November 1987, a structured QA program was initiated for flight nurses. Each chart was audited for completeness of 69 elements from seven categories: administrative information, patient history, physical exam, management plan, vital signs, medications and intravenous access. A comparison of audit results was conducted before and after the QA program was initiated. A total of 224 charts were audited, 123 before the QA program and 101 after. There was statistically significant improvement in 4 of 13 administrative, 5 of 7 history, 21 of 31 physical exam, 2 of 6 management, 2 of 2 vital signs, 0 of 4 medication, and 0 of 6 intravenous access elements. Twenty-five of 35 categories that did not show improvement had initial completion rates greater than 90 percent. The significant improvement in documentation by flight nurses after a formal QA program was initiated lead the authors to conclude that QA benefits air medical programs by providing a mechanism to improve documentation.