Use of Electronic Nurse Reminders to Improve Documentation: A Process Improvement for a Comprehensive Stroke Center.

Abstract

Nurses on a neurological step-down unit were challenged to switch from documenting assessments by hand to documenting by using a highly technological, electronic format. Upon the switch to electronic documentation, it was discovered through a chart audit that neurological assessments were not being documented properly. The purpose of this project was to implement Care Organizer, an electronic nurse reminder tool, on a neurological step-down unit and to evaluate the tool's ability to assist RNs in documentation of neurological assessments. Fifty patients' charts were audited for documentation of neurological assessments. Thirty-two RNs completed an anonymous demographic survey and were provided with eight training sessions related to utilization of Care Organizer. The RNs were asked to complete an evaluation of the tool 2 weeks after training and again at 1 month after training. A second chart audit was conducted at 1 month to assess for improvement of documentation 1 month after training. Preimplementation/postimplementation chart audits revealed improvements in documentation of neurological assessments in seven of eight criteria examined. Nurses admitted discomfort with Care Organizer and verbalized concerns that it was not convenient and/or user-friendly. Most admitted that with collaboration between information technology department and nursing, the tool could be further developed to become more applicable to nurses.