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Background
This clinical update describes the process and outcomes of a quality initiative aimed at improving nursing documentation in a large teaching hospital in Sydney. In 2007 a group of clinical nurse consultants (CNCs) and nurse educators formed a working party to address identified deficiencies in the quality of nursing documentation. As highlighted in a previous article in this journal (Gregory et al 2008), the working party assumed that nursing care based on the fundamental concepts of assessment, planning, implementation and evaluation would be reflected in the intension, clarity and flow of nurses' patient notes.
The first phase of the project involved the documentation of a policy to guide nurses in the correct way to document clinical notes. At the same time a specific nursing audit tool was developed to capture the quality of nursing documentation. During phase two a baseline audit was conducted. The deficiencies identified in the audit together with the documentation policy, formed the basis for a continuing education program (phase three). A repeat audit was undertaken in May 2009 to evaluate the effect of the education strategies implemented following the initial audit findings.
Project phases
1. Development of audit tool and documentation policy/guidelines
2. Baseline audit
3. Development and initiation of education strategy
4. Evaluation audit
Method
Phase one: development of audit tool and documentation policy/guidelines
As the project aimed to capture an impression of the quality of documentation, a specific audit tool was developed, refined, validated and published in a previous edition of the ANJ (Gregory et al 2008). The audit tool consists of two main sections. The items in section one are mandated by policy (NSW Health,2005) and are a common component of most nursing documentation audits. The second section of the audit tool was designed to capture meaningful information regarding the quality of the documentation. The areas addressed in this section included evidence of patient progress, assessment on admission to the ward, evidence of contemporaneous documentation and existence of and regular documentation on a nursing care plan or clinical pathway.
The final component in the quality section was evidence of objective assessment of situation, action and outcome (SAO). The SAO refers to an event or "situation" that has occurred, the action taken and the evaluation of a patient's...