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Communicating Safely: Standardizing Nursing Clinical Reports in a Neonatal Unit
Margaret Broom1, Laura Briguglio, Mekha Sam
1Author Affiliations: Neonatology, Centenary Hospital for Women and Children, Canberra, Australian Capital Territory, Australia (Dr Broom, Mrs Briguglio, Mrs Sam, Mrs Grlj, Mrs Martinoski); School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia (Dr Broom) and School of Nursing and Midwifery, University of Canberra, Canberra, Australian Capital Territory, Australia (Dr Broom).
Background:
Clinical documentation during nursing handovers is critical for safe neonatal care. Poorly structured or inconsistent documentation can lead to miscommunication, delayed interventions, and fragmented care. A 2021 audit in a tertiary neonatal unit revealed only 2% of nursing handover reports followed the recommended Introduction, Subjective, Objective, Assessment, Plan (ISOAP) format, posing significant risks to patient safety.
Purpose:
This quality improvement initiative aimed to improve compliance with ISOAP documentation format for nursing handovers in a tertiary Neonatal Intensive Care and Special Care Nursery (NICU/SCN), addressing both paper-based and digital systems.
Methods:
A 3-year quality improvement project was conducted using the Institute for Healthcare Improvement's Model for Improvement. Two Plan-Do-Study-Act (PDSA) cycles were implemented. PDSA Cycle 1 focused on paper-based documentation, while PDSA Cycle 2 targeted Digital Health Records (DHR). Interventions included the development of neonatal-specific ISOAP templates, education sessions, peer mentorship, visual reminders, and ongoing staff support. Compliance was measured through pre- and post-intervention audits.
Results:
Baseline adherence was 2% in February 2021. Following PDSA Cycle 1, adherence rose to 78% by January 2022 and reached 100% by March 2022. During the DHR transition, adherence improved from 65% in May 2023 to 92% by July 2023. Staff reported improved clarity, enhanced communication, reduced time required for clinical reviews, and greater satisfaction with documentation processes.
Implications For Practice And Research:
Structured education, standardized templates, and peer support effectively improved documentation compliance. Future research should explore the impact of standardized handover documentation on neonatal outcomes and further strategies for optimizing digital implementation.
Related Concept Videos
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:20Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
01:28Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
01:24Data Reporting and Recording
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:25Types of Reports I: Hand-off Report
Following are the key components and categories of hand-off reports:
Purpose and Process: