ERIC Number: ED575559
Record Type: Non-Journal
Publication Date: 2017
Pages: 96
Abstractor: As Provided
ISBN: 978-1-3696-6527-7
ISSN: N/A
EISSN: N/A
Improving the Quality of Nursing Documentation in Home Health Care Setting
Obioma, Chidiadi
ProQuest LLC, D.N.P. Dissertation, Walden University
Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the quality of documentation of patient care in nurses' notes in a home health agency in central Texas. A retrospective audit of quality of nursing documentation using the Nurse and Midwifery Content Audit Tool (NMCAT) was done. A pre- and posttest design was used. A convenience sample of de-identified nurses' notes (80 pre- and 80 post) was selected from active patient records in the agency (n = 160). Descriptive and inferential statistics from the project showed that there was improved quality for the 15 criteria representing quality nursing documentation. After the educational intervention, documentation of patient's status if changed or unchanged improved to 80%, and patient's response to treatment improved (57% to 85%), entries were written as incidents occurred improved (53% to 64%). The nurse refers to the patient by name improved (0% to 66%). These findings were an indication of practice change, validating the need for periodic audits of nurses' notes in the agency in order to demonstrate compliance with quality standards. Based on the project findings, a retraining program is recommended to improve structured nursing documentation in a home health agency. This project is likely to contribute to social change as it enhanced the information communicated to other health care providers, coordination of care, and patient outcomes. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://bibliotheek.ehb.be:2222/en-US/products/dissertations/individuals.shtml.]
Descriptors: Nursing, Health Services, Pretests Posttests, Patients, Home Programs, Documentation, Nurses
ProQuest LLC. 789 East Eisenhower Parkway, P.O. Box 1346, Ann Arbor, MI 48106. Tel: 800-521-0600; Web site: http://bibliotheek.ehb.be:2222/en-US/products/dissertations/individuals.shtml
Publication Type: Dissertations/Theses - Doctoral Dissertations
Education Level: N/A
Audience: N/A
Language: English
Sponsor: N/A
Authoring Institution: N/A
Identifiers - Location: Texas
Grant or Contract Numbers: N/A