Date of this Version
Nursing documentation is a fundamental clinical routine that improves safety of care. It is utilized for communication within healthcare team members and other disciplines, credentialing, legal matters, and to measure performance outcomes. In the healthcare profession, it is crucial to provide quality nursing documentation. There is an increase in non-adherence and documentation errors amongst nurses. A quality improvement project was developed with the goal to improve nurse’s knowledge on quality nursing documentation and improve nurses’ attitude and adherence to documentation. The project was obtained in an inpatient behavioral unit located in an urban South Florida hospital. Participants included nurses who work on the inpatient behavioral units.
A comprehensive literature review was conducted using research data bases such as CINAHL and MEDLINE to identify studies relevant to quality nursing documentation. The quality improvement project utilized a pretest entailing the general self -efficacy scale and posttest. A total of thirty nurses contributed to the quality improvement project. Results of the pre-test indicated nurses in the inpatient behavioral unit have a perceived positive self-efficacy, thus likely to adhere to improving documentation requirements. Overall, fifty- nine percent agreed that their attitude changed about documentation. In addition, results displayed a 17% increase to nurses’ knowledge about quality documentation after engaging in the educational in-service
Francois, Nicole, "Nursing Documentation in an Inpatient Behavioral Health Unit: A Best Practice Quality Improvement Project" (2021). Nicole Wertheim College of Nursing Student Projects. 44.