DescriptionPurpose: To improve nursing documentation, nurse leaders need the knowledge, skills and tools to evaluate nursing documentation. The purpose of this project was to provide nurse leaders with a toolkit of how to evaluate nursing documentation and implement a sustainable monitoring process to ensure nursing documentation guidelines are adhered to.
Methodology: Nurse leaders on an in-patient unit received a one-hour education module on the toolkit over 1 week. Then weekly, 1-hour coaching sessions with the nurse leaders occurred over 4 weeks which included standardized questions to elicit feedback on the toolkit. The number of pain documentation discrepancies were measured for 4 weeks before the intervention, during the 5-week intervention period and 4 weeks post-intervention to determine if the toolkit made an impact on nursing documentation.
Results: The primary outcome measure, a reduction in the pain documentation deficiencies, was achieved during the intervention period; however, the deficiencies resumed to previous levels immediately following the intervention period. The responses to the open-ended questions by the project participants perceived the nurse leader toolkit components and process as easy to use, effective and valuable.
Implications for Practice: The project findings show promise in using the toolkit to support the nurse leaders in monitoring adherence to an accurate patient record. This project increased nurse leaders’ knowledge and demonstrated that nurse leaders need the knowledge, skills and tools to successfully led. The staff nurse driven unit practice councils is a forum where the results and findings of this project can be shared to advance the efforts of improving nursing documentation.