Abstract TP351: Don’t Break My Chart, My Achy Breaky Chart: Improving Nursing Documentation for Stroke Outcomes

Abstract

Background: Hospitals, including community hospitals, often face challenges in the care of the acute stroke patient. One of these challenges is consistent documentation of core measures. Specific documentation opportunities at our hospital included documentation of neurological assessment and care plans. The Progressive Care Unit had a significantly higher rate of opportunities for improvement with documentation when compared to other units in our facility. Purpose: The purpose of this process improvement project was to improve compliance with neurological assessment and care plan documentation for stroke patients identified through concurrent chart review. Methods: Prior to classroom sessions, a needs assessment was completed by unit nursing staff to gather baseline data of their compliance in completing the documentation of neurological assessment and care plans. The Stroke Program Manager, Unit Educator, Clinical Nurse Specialist, and Nursing Informaticist collaborated to develop a curriculum to address our documentation opportunities. This curriculum consisted of a lecture with PowerPoint presentation, hands on documentation utilizing a patient scenario, and the development of pocket reference cards for stroke specific documentation. Results: Progressive Care Unit nursing staff had an average of 13.3 documentation fallouts per month prior to education efforts. The Progressive Care Unit nursing staff decreased the number of documentation fallouts to an average of 5.7 per month following the completion of documentation education. This improvement demonstrates a 57.1% reduction in documentation fallouts. Conclusion: In conclusion, stroke programs continue to experience challenges with compliance in neurological assessment documentation. With the implementation of specific education we were able improve the overall nursing documentation for stroke patients in the Progressive Care Unit.