Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi-experimental study.
communication
documentation
electronic medical records
emergency department
emergency nursing
nursing
Journal
Journal of clinical nursing
ISSN: 1365-2702
Titre abrégé: J Clin Nurs
Pays: England
ID NLM: 9207302
Informations de publication
Date de publication:
Oct 2022
Oct 2022
Historique:
revised:
30
09
2021
received:
02
08
2021
accepted:
16
10
2021
pubmed:
19
11
2021
medline:
8
9
2022
entrez:
18
11
2021
Statut:
ppublish
Résumé
To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation. Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown. A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data. The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly. Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations. The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.
Sections du résumé
AIMS AND OBJECTIVES
OBJECTIVE
To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation.
BACKGROUND
BACKGROUND
Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown.
DESIGN
METHODS
A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist.
METHODS
METHODS
HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data.
RESULTS
RESULTS
The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly.
CONCLUSION
CONCLUSIONS
Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations.
RELEVANCE TO CLINICAL PRACTICE
CONCLUSIONS
The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.
Types de publication
Journal Article
Langues
eng
Pagination
2874-2885Subventions
Organisme : New South Wales Agency of Clinical Innovation
Informations de copyright
© 2021 John Wiley & Sons Ltd.
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