Degree Name
Nursing Practice, DNP
Publication Date
8-4-2025
First Advisor
Sandy King
Second Advisor
Kristie Givens
Abstract
Accurate nursing documentation plays a vital role in ensuring high-quality patient care, yet inconsistencies remain a common challenge, particularly with preventive screenings like pediatric tobacco use. Research shows that when documentation is incomplete or incorrect, opportunities to identify and intervene with at-risk adolescents are often missed. This quality improvement project was developed to address a specific gap in documentation practices at a community health clinic, where staff often failed to consistently complete the pediatric tobacco screening tool. The goal of the project was to determine whether evidence-based education, combined with chart audits and feedback, could improve the consistency in which these screenings were conducted. Using a quasi-experimental mixed-methods design, the project included pre- and post-intervention surveys to assess knowledge, attitudes, and documentation practices, as well as retrospective chart audits over a five-week period. The intervention included staff education, documentation training, and bi-weekly feedback. While some improvements were seen in areas such as language barriers and patient concentration, overall completion rates of the screening tool did not show a statistically significant change. These results suggest that more targeted strategies, such as individualized feedback, may be needed to drive lasting improvement. This project underscores the critical role nurses play in improving documentation practices and highlights how nurse-led interventions can contribute to better patient outcomes across healthcare systems.
Rights Management
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Jones, Amber, "Quality Improvement Project Data at Risk: The Implications of Inconsistent Nursing Documentation on Patient Care Interventions" (2025). Doctor of Nursing Practice Projects. 152.
https://arch.astate.edu/dnp-projects/152
