A Project for Improving the Nursing Record Writing Completeness Rates of Nursing Care Staff

Abstract

A complete nursing care record is an essential element of patient safety and medical care quality, which is conducive to communication within a medical team. Therefore, it is necessary to achieve completeness and thoroughness of those records. The Ad hoc group conducted an inspection on nursing care record writing completion, only reaching 80.7%, lower than the threshold during the period of July to September, 2014. Through the analysis of the current situation, the established reasons are: too busy to write records promptly, different writing content knowledge standards, the lack of a consulting talent pool, inspection results not being advocated and announced, the lack of writing record examples and in-service education and reminder slogans, and other factors. Targeting the above reasons, the strategies proposed to solve these problems include: producing reminder cards and nursing care record writing samples, announcing the list of incomplete writing and inspection results, strengthening ward meeting advocacy, organizing in-service education, setting up nursing care record writing case seminars and a consulting talent pool, seven items in all. After implementation, the nursing care record writing completion rate increased from 80.7% to 97%. The project improvement strategy is expected to serve as a model for future nursing care record writing and improve care.