Degree Name
Nursing Practice, DNP
Publication Date
8-4-2023
Upload Date
2024
First Advisor
Debra Schulte
Abstract
Nursing documentation is a critical element of the patient's medical record and contains essential information relied upon to create and implement the plan of care. Despite the understood importance of timely documentation, nurses in this community hospital inpatient medical/surgical unit still struggle to complete data entry promptly. This quality improvement project aimed to improve the efficiency and timeliness of nursing documentation in this unit by deploying the EMR on a mobile application as an adjunct to desktop and laptop PC devices. EMR reporting tools were used to collect timestamps of flowsheet documentation observation time and observation entry time. Time in minutes and percentage of documentation completed in real time (≤60 minutes) were reported as continuous data for 21 days pre-intervention and 21 days post-intervention to determine if adding the mobile device improved the timeliness of data entry. A parametric independent samples t-test analysis revealed a statistically significant improvement in the average number of minutes from observation to documentation and the average percentage of documentation occurring in real-time. These results indicate that the defined intervention was effective at improving the timeliness of documentation in this quality improvement project.
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Morgan, Anthony S., "Improving Timeliness of Nursing Documentation" (2023). Doctor of Nursing Practice Projects. 39.
https://arch.astate.edu/dnp-projects/39
