Improving the quality of nursing documentation on an acute medicine unit

An action research project was undertaken to explore issues underpinning poor quality documentation and how improvement in assessment can be achieved and sustained.

To improve nursing documentation, as well as the quality of nursing assessments and evaluation in an acute medicine unit using anaction research approach.

Nurses from an acute medicine unit helped develop a new process for assessment documentation. Five pieces of documentation were radically changed and three new pieces developed. During testing, four cycles of action research w ere completed; as a result, focused interventions were made to the documentation and assessment process to promote improvement in the areas that demonstrated poor completion or compliance. The new documentation was evaluated for degree of completion and compliance with the new process. RESULTS DOCUMENTATION: the quality of entries recorded, and compliance improved. Documentation was also more up to date. Staff commitment helped unravel issues underpinning poor completion/compliance to the original documentation and assessment process.

Care planning must be taught in pre-registration training as a fundamental principle of care. Understanding issues pertinent to a busy area and designing a process that makes completion of documentation easier means changes can be sustained long after the active stages of action research have been completed.