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Related Experiment Videos

Implementing mandatory early warning scoring impacts nurses' practice of documenting free text notes.

Gitte Bunkenborg1,2, Lars Smith-Hansen3, Ingrid Poulsen4,5

  • 1Department of Anesthesiology, Copenhagen University Hospital, Hvidovre, Denmark.

Journal of Clinical Nursing
|April 3, 2019
PubMed
Summary

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Implementing the Modified Early Warning Score (MEWS) significantly improved nurses' free text notes on Airway, Breathing, and Circulation. This enhanced documentation supports better patient situation awareness and clinical communication.

Area of Science:

  • Nursing Informatics
  • Patient Safety
  • Clinical Documentation

Background:

  • Quality nursing documentation is crucial for patient safety but faces challenges in both paper and electronic health records.
  • Nurses' ability to convey a comprehensive patient status is often compromised.
  • The Modified Early Warning Score (MEWS), proven to reduce unexpected deaths, may influence nurses' free text documentation.

Purpose of the Study:

  • To evaluate the impact of implementing the Modified Early Warning Scoring (MEWS) system on nurses' free text notes.
  • To assess changes in documentation related to Airway, Breathing, Circulation, and Pain in general medical and surgical patients.

Main Methods:

  • A prospective, pre- and postinterventional, non-randomized study design.
  • Analysis of 1,497 patient records from a Danish university hospital.
Keywords:
clinical observationdocumentationfree text notesnursingpatient safetyrecord keepingsituation awareness

Related Experiment Videos

  • Comparison of nurses' free text notes before and after MEWS implementation, focusing on the 56-hour period surrounding initial vital parameter deviations or a MEWS score ≥ 2.

    • Main Results:

    • A significant increase in nurses' free text notes concerning patients' breathing was observed in the 8-hour shift of initial vital parameter deviations.
    • A significant increase in free text notes related to Airway, Breathing, and Circulation symptoms was identified in the 24 hours following initial deviations.
    • The study demonstrated a positive impact of MEWS implementation on the detail and frequency of nursing documentation.

    Conclusions:

    • Mandatory implementation of the Modified Early Warning Score system significantly enhances nursing free text documentation.
    • Supporting nurses' communication of clinical symptoms through free text notes is vital for improving situation awareness.
    • The findings underscore the importance of structured scoring systems in improving the quality of clinical records.