Student Dissertation

Agency : Gap Analysis; Nurse’s Documentation; NABH Standards; JCI Standards; Nurse Audit

Objective : • To design a nurse toolkit for auditing the nursing documentation in IPD area of the hospital. • To identify the gaps in nursing documentation in IPD area of the hospital • To suggest measures to improve timely and accurate documentation by nurses.

Background : Nurses are the backbone of the hospital. Starting from the entry of the patient in the ward till the discharge of the patient, nurses play a major role in the recovery of patient’s condition. During the stay of the patient in the hospital, it is nurse’s responsibility to document the care provided, e.g. medicines administered, vitals monitoring, assessment of the patient etc. Nursing documentation in the patient records helps in continuity of care of the patient and helps to understand the course of treatment in the hospital. However, with increase in workload, the importance of timely and accurate documentation in the patient records is sidelined and is often overlooked. This might lead to discrepancies in the hospital charges leading to revenue loss, indicate errors in the care processes and infringe on ethical and legal aspects of the category. This study was conducted in Moolchand Hospital to understand the gaps in the nursing documentation according to NABH and JCI standards in the IPD areas. The study was conducted over a period of three months (6 February 2017 to 6 May 2017). Nearly 250 Inpatient records were audited with the help of a nursing audit toolkit.

Methodology : Study Design: Cross sectional descriptive study. Setting: Moolchand Hospital, New Delhi. Duration of study: February 2017 to May 2017. Sample Size: Total 254 case records Sampling Technique: Convenient sampling technique

Findings : • Compliance in documentation of vitals, handover signatures, BAR sheet is maximum on third floor (85%,71%, 74.6 % respectively) as compared to other floors. • Initial assessment and nutritional screening are not done within 30 minutes in majority of the cases. Maximum compliance of initial assessment is seen on first floor (30%) and minimum is seen on third floor (7%). • Nutritional screening has lower compliance as compared to other parameters audited on GF, FF, TF, IW (3%, 2.6%, 7%, 6%) respectively. • In all the cases with high risk medication administration, nurse’s counter sign was missing. Hence there is 100% partial compliance with only one nurse signature on administration record • Documentation of patients’ name and HUID has 100% compliance in records of the floors audited. • Patient identification check by ID band is maximum followed in first floor (97.4%) followed on third floor (97%) and least compliance percentage is of international wing (94%).

Recommendations : • Quality nursing documentation promotes structured, consistent and effective communication between caregivers and facilitates continuity and individuality of care and safety of patients. • The accuracy of documentation content in relation to patients’ actual conditions and the care given is an important process feature of documentation quality. • From the study, it can be concluded that the nursing care was not fully expressed in the records, so written communication between different caregivers about patients was inadequate.


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