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Improving clinical documentation quality

P Quigley¹, A Mathis, V Nodhturft

¹James A. Haley Veterans Affairs Medical Center, Tampa, FL.

Journal of Nursing Care Quality

|July 1, 1994

Summary

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A multidisciplinary team revised nursing documentation, enhancing patient care plans and charting systems. This initiative improved documentation quality through collaboration and commitment.

Area of Science:

Nursing Informatics
Healthcare Quality Improvement
Clinical Documentation

Background:

Traditional nursing documentation methods were outdated and inefficient.
A need existed to standardize and improve the quality of patient care documentation.
Existing nursing care plans lacked individualization and flexibility.

Purpose of the Study:

To overhaul the nursing admission assessment form.
To replace handwritten nursing care plans with a more efficient system.
To integrate standards of care and practice into individualized patient care plans.

Main Methods:

Formation of a multidisciplinary documentation quality team.
Revision of the admission nursing assessment form.

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Development of flexible charting systems and clear documentation guidelines.

Main Results:

Successful revision of the nursing assessment form.
Elimination of traditional handwritten nursing care plans.
Implementation of a system for individualized patient care plans based on standards.
Establishment of flexible charting systems for specialty areas.

Conclusions:

Commitment, collaboration, and cooperation were key to successful documentation quality improvement.
The project enhanced the efficiency and effectiveness of nursing documentation.
Outcomes demonstrate a significant improvement in the basis for individualized patient care.