Abstract
The current practice of fluid intake and output monitoring for hospitalised patients in one local acute care tertiary hospital was unclear and inconsistent. Inaccurate fluid balance monitoring and poor documentation can result in poor clinical outcomes. To provide an overview of the current practice of ordering, monitoring and documentation of patient fluid intake and output during hospitalisation. Electronic charts of 2199 adults were reviewed for appropriateness and accuracy of monitoring and documentation of the fluid balance records. Data retrieved for each patient included: (1) Was daily fluid balance monitoring clinically indicated? (2) Was daily fluid balance monitoring prescribed by the doctors or initiated by the nurses? (3) Was the daily fluid balance documentation accurate for the entire admission? Of the reviewed patients, 68% were on fluid balance monitoring, of whom 31% were prescribed by medical teams and 69% were nurse-initiated. Among patients who were receiving fluid balance monitoring, 78% were clinically indicated (35% prescribed by doctors), and 22% had no clinical indications (18% prescribed by doctors). Overall, documentation accuracy of the intake and output charts was 77%, with 100% accuracy in the oral and intravenous fluid intake, and 21% accuracy in the output documentation. Among the inaccurate documentation of monitoring with no quantifiable amount, 'void in toilet' was the most inaccurately documented (93.3%). It is vital to address the current disparities in hospital practice, which include prescribing fluid balance monitoring for patients without a clinical indication and documenting incomplete or poor quality information in patients' intake and output charts. Future quality improvement and research work is needed to improve patient safety and outcomes.
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Disclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.