Degree Name
Nursing Practice, DNP
Publication Date
12-1-2025
First Advisor
Sandy King
Abstract
Accurate and timely documentation are essential for safe, high-quality care in community mental health settings. This quality improvement (QI) project addressed inconsistent documentation practices among licensed, unlicensed, and Qualified Mental Health Specialist (QMHS) staff at an outpatient clinic. The purpose of the QI project was to implement and assess a structured in-service training program using the Accountable Health Communities–Health-Related Social Needs (AHC-HRSN) screening and documentation tool to improve staff knowledge, enhance documentation accuracy, and facilitate care coordination. Guided by the Iowa Model of Evidence-Based Practice and Lewin’s Change Management Model, a pre- and post-intervention design was used. Fifteen staff members participated in a seven-week training, with data collected through a 13-item survey that included multiple-choice knowledge questions, Likert-scale confidence ratings, and staff role variables, both before and after the intervention. Descriptive and inferential statistics, including the Wilcoxon signed test, showed significant improvements in knowledge and confidence scores. Limitations included a small sample size and a single-site setting. The project demonstrates that structured, evidence-based training can improve documentation practices, enhance regulatory compliance, and positively impact patient outcomes. These findings support ongoing education and the use of standardized tools as sustainable strategies to advance care in behavioral health settings.
Rights Management
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License
Recommended Citation
Parker, Carol, "Quality Improvement Project Enhancing Documentation Practices in Community Mental Health Clinics" (2025). Doctor of Nursing Practice Projects. 264.
https://arch.astate.edu/dnp-projects/264
