IMPROVING NURSING DOCUMENTATION TO FACILITATE MULTI- DISCIPLINARY COMMUNICATION AND QUALITY HANDOVERS (PEAPODSS)

Background The health care team are responsible for adequate patient documentation to enable effective patient centred care. Anecdotally members of the oncology health care team had noted inpatient nursing documentation lacked clarity and detail. The Essentials of Care (EoC) program was employed to address this. Method A workshop using the EoC methodology was conducted with key stakeholders to identify and evaluate the issues. A pre and post chart audit was performed to assess nursing documentation. A satisfaction survey of stakeholders was undertaken 2 months following the introduction of the nursing documentation prompts. A list of key nursing documentation prompts was developed. Nursing staff were educated in the use of the nursing documentation prompts in key areas of care relevant to oncology patients using EoC principles. All nursing staff were encouraged to use the prompts to document patient care on each shift. Results The initial chart audit demonstrated and confirmed the anecdotal reports of a lack of detail in patient medical records necessary to facilitate multidisciplinary communication, handover and quality care. The most recent audit, two months after the introduction of the prompt list, demonstrated an overall improvement in the documentation required to facilitate patient centred care in the key area of care. Conclusion The results of the satisfaction survey indicate the prompt list, and education has helped improve overall communication and improve relevance for  accurate detail in nursing documentation. The major barrier identified by nurses was the amount of time they needed to complete documentation using prompts. Preliminary results from the nurses’ satisfaction survey demonstrate nurses have experienced positive benefits to patient care when using prompts to document. Recommendations EoC as a model for change, re-evaluate and refine prompt list further to ensure continued improvement and continuing education for new staff.