Maintaining high quality clinical documentation is essential for a number of reasons, including improved patient safety and better adherence to accreditation standards. Marie Boyd, administrator at Cape and Islands Endoscopy Center in Hyannis, Mass., shares four steps ASCs can take to improve their nurses' documentation in patient charts.
1. Conduct data collection. In order to improve upon the accuracy and completeness of nurses' documentation in medical charts, an ASC first must root out the major deficiencies or errors that tend to occur.
"Every month, 5 percent of medical charts are pulled and reviewed by a nurse, physician and an administrator. We noticed an increase in documentation errors, so we decided to conduct a benchmarking study between April and June," Ms. Boyd says. "That's what compelled us to do the study and try to rectify the problem. So now we're currently in another process of compiling data on nursing documentation."
2. Apply a procedure to remedy the documentation problem. To ensure proper documentation at Cape and Islands Endoscopy, medical charts went through two rounds of review with two nurses. Ms. Boyd says the two nurses dedicated time either throughout or at the end of each day to go through every patient chart that was handled that day.
"Whenever they had time, two of our nurses spent a part of each day going through every patient chart from that day and documenting every error," Ms. Boyd says. "Errors ranged from nurses failing to document the number of the gastroscope used during a patient's visit to lack of pre- or post-procedural calls to patients. This way, we can also identify patterns in what staff members aren't documenting properly."
3. Tweak the procedure for improved QI effectiveness. Ms. Boyd adds that while the idea of bringing on a second nurse to assist in medical chart reviews seemed reasonable, she very quickly realized that the double coverage wasn't necessarily helping to reduce the incidence of improper nursing documentation.
"We haven't concluded our study quite yet, but we did discover that while fewer errors were occurring in medical charts, having a second nurse at the end of the day to review them didn't solve the problem adequately enough," she says. "It's not time- or cost-effective to have the second nurse stay late or to review a chart at the end of a long day. We are now in the process of changing that practice, and instead having a second set of fresh eyes review the charts the morning after."
4. Communicate the issue and re-educate your nurses. Although implementing a formalized process or procedure to ensure proper nursing documentation is one proactive measure to take, communicating the issue directly with nurses is equally essential. Improvements on nursing documentation were almost immediate upon making nurses aware of how important it is to spend more time on medical charts, Ms. Boyd says. She adds that including physicians in the peer review process has been another approach to completing missing fields and simultaneously maximize physician awareness.
"We don't want to pinpoint fingers at any of the nurses, but we do want to go over with them again how to properly fill out medical charts, what should be documented and so on," Ms. Boyd says. "It could be as simple as telling another nurse who didn't fill out details of the post-procedural call that even if the patient's number was not in service and that nurse tried alternative numbers, details on the post-procedural call shouldn't be left out. All those deep details should actually be included in the medical chart."
Learn more about Cape and Island Endoscopy Center.