Improving quality of nursing documentation

Peer review chart audit and feedback process to improve quality of nursing documentation in an inpatient labor and delivery unit

Binni Hagstrom

DNP focus area: Health Systems Leadership and Informatics

 

Nursing has an important role in clinical documentation by producing comprehensive, reliable, accurate data that facilitates the patient care and captures the clinical picture. In an inpatient labor and delivery unit in an academic center, documentation was incomplete as identified by the unit data analyst monthly report. A workflow analysis highlighted the need for corrective action on documentation practices as it demonstrated inaccurate documentation and represented a threat to the quality of care.

To improve nursing documentation, an intervention of peer chart auditing and feedback for accuracy and completeness in nursing documentation was initiated.

The quality improvement project used Plan-Do-Study-Act cycles of peer chart review and feedback using an audit tool. Nurses were educated and oriented to the audit tool and feedback process. Nurse feedback led to changes in the audit tool clarity and usability. Nurses received individualized coded feedback of audits through sealed envelopes and anonymous results were disseminated electronically and through staff huddles after each cycle to analyze documentation improvement as a unit.

The measures focused on four different areas of Labor and Delivery documentation, the delivery summary, recovery, intake and output, and nursing care plan. The process increased documentation completeness and accuracy from 80% to 90% in the delivery summary, 50% to 69% accuracy in recovery, 52% to 71% in intake and output, and 12% to 50% in nursing care planning documentation. This improvement yielded a more complete clinical picture of the patient through the five cycles of auditing. In conclusion, to increase accuracy and consistency in documentation that reflect quality nursing care can be achieved through a peer chart audit and feedback process.