Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite...

Area of Science:

• Emergency Nursing
• Clinical Documentation Accuracy
• Healthcare Quality Improvement

Background:

• Accurate clinical documentation is crucial for safe and high-quality patient care in nursing.
• The HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) framework enhances emergency nursing care by reducing delays and improving escalation of deterioration.
• The impact of the HIRAID framework on nursing documentation accuracy was previously unknown.

Purpose of the Study:

• To evaluate the effectiveness of the HIRAID emergency nursing framework in improving the accuracy of clinical documentation.
• To assess changes in the completeness and correctness of nursing records after HIRAID implementation.

Main Methods:

• A quasi-experimental pre-post study design was employed, adhering to the STROBE checklist.
• The HIRAID framework was implemented across four Australian regional/rural emergency departments using behavior change strategies.
• Electronic health records of 120 patients (shortness of breath, abdominal pain, fever) were analyzed for documentation accuracy using quantitative and qualitative measures.

Main Results:

• Implementation of HIRAID led to a significant increase in essential assessment components within patient records.
• Improvements in documentation accuracy were observed across pediatric and adult populations and for all presenting conditions.
• Both quantitative and qualitative assessments showed significant improvements in the recording of patient history and physical assessment findings.

Conclusions:

• The HIRAID framework demonstrably enhances the accuracy of clinical documentation, particularly for patient history and physical assessments.
• The study recommends the adoption of the HIRAID framework in clinical practice to improve documentation accuracy among emergency nurses.