Improving nurse's documentation in the emergency department
Jacqueline N. Wright-Cole, DNP, MSN, RN, PCCN-K
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The appropriate documentation and effective hand-off communications are essential components for attaining and maintaining the continuity of quality care for patients in the emergency department. Despite global efforts and standards geared towards improving the accuracy and function of documentation, the issue of incomplete documentation and hand-off communication persist in the local emergency department. Incomplete documentation and handoff communications have been regarded as key factors of delayed patient care as well as discontinuation of care in the clinical setting. A detailed study conducted for evaluating the effectiveness and benefits of the Institute Healthcare Improvement SBAR guideline as a checklist on nurses’ documentation and hand-off communications was conducted in the local Emergency Department. The pre and post design utilizing the SBAR Assessment tool adapted from Sears, et al. (2014) was used for collecting data from a convenient sample of 30 nurses. Evaluation of the study revealed clinical significance where 96.7% of the participants believed that the SBAR checklist tool positively influenced effective communication between the healthcare team, patients and families creating a culture of safety for both the patient and the nurse. While 50% of participants believed that the checklist reminded them of important information to document and their message was fully received and understood. The findings from the study have positive implications for the clinical setting to assist in cultivating a climate of safety for the patients, nurses, the organization and the community to maintain a positive outcome.
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Quality of Care
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