Documentation Compliance Research Articles

Abstract TP5: Helicopter Emergency Medical Services (HEMS) Transportation Utilization For Acute Ischemic Strokes At A Community Based Hospital In South Florida

Background: Efficiency in the transfer of patients with ischemic stroke is a vital factor for patient prognosis. A comprehensive stroke center servicing remote areas in south Florida became HEMS direct-from-field capable on October 15, 2020. In some remote areas, the transfer of patients is via ground or air; the severity of the clinical presentation determines the mode. Concern about HEMS overutilization for lower stroke acuities prompted this study. Purpose: The purpose of this project was to evaluate the current HEMS stroke triage process, assess the accuracy of stroke diagnosis, and use this information to improve EMS education to prevent over-triage for stroke. Methods: A retrospective cohort study from October 15, 2020, to July 31, 2021, collected HEMS adult stroke alert data and compared it to the prior year's summary ground EMS (GEMS) stroke alert data. Using HEMS transportation logs, presenting stroke symptoms and pre-hospital assessment were abstracted. In addition, we evaluated initial NIHSS, downgrade rate, stroke diagnosis percentage, treatment rate, and times. Results: The analysis included a total of 52 HEMS stroke alerts. Assessment tools utilized by HEMS included the Cincinnati stroke scale (4%) and the FAST-ED (37%); the majority of cases (59%) did not document a stroke assessment tool. The median NIHSS was 10, with 37% presenting with a score <6. Respectively, 6% and 15 % of cases were downgraded upon arrival and after CT imaging. Significantly (p<.001), more HEMS cases were diagnosed as a stroke (69%) compared to GEMS (57%). Stroke treatment rates remained similar (HEMS=23%; GEMS=23%). Median door-to-needle times were significantly faster for HEMS (15min) than GEMS (25min) (p<.05). Median door-to puncture times were significantly faster for HEMS (61mins) than GEMS (72mins) (p<.05). Conclusion: With low downgrade rates and high diagnosis accuracy, the current HEMS triage process, although not consistently documented, accurately detects stroke, even for low acuity cases. Patients arriving via HEMS receive equal access to stroke treatment with significantly faster treatment times, ensuring the best possible prognosis. EMS educational efforts should focus on improving documentation compliance.

Involving users in the development of a modeling language for customer journeys

Although numerous methods for handling the technical aspects of developing domain-specific modeling languages (DSMLs) have been formalized, user needs and usability aspects are often addressed late in the development process and in an ad hoc manner. To this concern, this paper presents the development of the customer journey modeling language (CJML), a DSML for modeling service processes from the end-user’s perspective. Because CJML targets a wide and heterogeneous group of users, its usability can be challenging to plan and assess. This paper describes how an industry-relevant DSML was systematically improved by using a variety of user-centered design techniques in close collaboration with the target group, whose feedback was used to refine and evolve the syntax and semantics of CJML. We also suggest how a service-providing organization may benefit from adopting CJML as a unifying language for documentation purposes, compliance analysis, and service innovation. Finally, we distill what we learned into general lessons and methodological guidelines.

A unit-based, multi-center evaluation of adopting mobility measures and daily mobility goals in the hospital setting

BackgroundPromoting patient mobility helps improve patient outcomes, but mobility status is not widely tracked nor do patients have specific individualized mobility goals. PurposeWe evaluated nursing adoption of mobility measures and daily mobility goal achievement using the Johns Hopkins Mobility Goal Calculator (JH-MGC), a tool to guide an individualized patient mobility goal based on the level of mobility capacity. MethodBuilt on a translating research into practice framework, the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program was the vehicle to promote use of the mobility measures and the JH-MGC. We evaluated a large-scale implementation effort of this program on 23 units across two medical centers. FindingsUnits significantly improved documentation compliance to mobility measures and achieving daily mobility goals. Units with the highest documentation compliance rates had higher rates of daily mobility goal achievement, especially for longer distance ambulation goals. DiscussionThe JH-AMP program improved adoption of mobility status tracking and higher nursing inpatient mobility levels.

Beban Kerja Perawat Berhubungan Dengan Kepatuhan Pendokumentasian Asuhan Keperawatan Di IGD RSUD Kota Bogor Tahun 2022

Introduction: Based on the data obtained from January to May 2022 in the Bogor City Hospital Emergency Room, it was found that the documentation of nursing care was not optimal. 7 Emergency Room nurses said that the workload of nurses was quite heavy with countless patient visits with various criteria. Incomplete documentation of nursing care will lead to a decrease in the quality of nursing services and the occurrence of a problem that has the potential to become a legal case for nursing staff. Therefore, it is necessary to increase knowledge regarding the completeness of proper documentation and motivation from leaders and management so that nurses can complete the documentation of nursing care optimally. Methods: This study uses a cross-sectional descriptive quantitative method, with the type of correlation. The samples taken were 42 respondents. The instruments used were the workload questionnaire from Nursalam and the Hospital Nursing Care Standards (SAK) observation sheet. The dependent and independent variables in this study were Compliance with nursing care documentation and nurses’ workload. Results: The age distribution where nurses were mostly early adults with 33 people (78,6%), and the gender of most of them was 29 people (69%), The distribution of nurses' workload is almost entirely moderate, namely 35 people (83,3%) while the distribution of documentation compliance level is mostly obedient, which is 24 people (57,1%). Correlation Test Results p-value was obtained at 0,031 (< 0,05). Discussion: There is a significant relationship between the workload of nurses and the compliance of nurses' documentation in Bogor City Hospital Emergency Room in 2022.

Results of an Audit of Orthopaedic Operation Notes from a Tertiary Care Centre: Are We Doing It Right and Can We Do More?

The Royal College of Surgeons (RCS) published the Good Surgical Practice guidelines in 2008 and subsequently revised them in 2014. Essentially, they outline the basic standards that need to be met by all surgical operation notes. The objective of the present study was to retrospectively audit the orthopaedic operation notes from a tertiary care hospital in Mumbai (between October 2020 to March 2021) against the recommended RCS Good Surgical Practice guidelines published in 2014. In the present study a total of 153 orthopaedic operation notes of 200 patients were audited by a single reviewer. During the period between October 2020 and March 2021, the data collection took place. All notes were typed on the standard operative proforma available on the hospital patient management software (SAP). Overall, the mandated fields in the EMR had excellent documentation. Documentation was excellent for the date and time of surgery, name of the surgeon, the procedure performed (100%), operative diagnosis (99.35%), an extra procedure performed (100%), and details of antibiotic prophylaxis (99.35); Inadequate for details of incision (94.77%), details of operative findings (92.16%), details of prosthesis (97.37%), DVT prophylaxis (96.08%) and detailed post-operative instructions (93.46%) and poor for tourniquet time (41.83%;), estimated blood loss (59.48%), closure details (16.99%), documentation of complications or lack of (51.63%) and setting of surgery elective or emergency (0%). Compliance for completion and documentation of operative procedures was high in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions. With wider adoption of electronic medical record systems, there is a scope of improving documentation by mandating certain fields.

Improvement of Procedure Documentation Compliance With the Implementation of a Visual Aid

BackgroundEmergency department (ED) providers face increasing task burdens and requirements related to documentation and paperwork. To decrease the mental task burden for providers, our institution developed an infographic that illustrates which forms are necessary for complete documentation of nonemergent invasive procedures. ObjectivesOur study aims to analyze the effect of a nonelectronic health record-based infographic, paired with direct feedback, on compliance with nonemergent invasive procedure documentation performed in the ED. MethodsThis was a retrospective, observational study of all procedure documentation performed in the ED with a pre-/post-test design. The study included two 8-month study periods, 1 year apart. The preimplementation period used for comparison was January 1, 2019–August 31, 2019, and the postimplementation period was January 1, 2020–August 31, 2020. All invasive procedures that required documentation in addition to a procedure note were included in the study. The primary outcome was the percentage of compliance with documentation requirements. ResultsDuring the pre- and postimplementation study periods, 486 and 405 charts with nonemergent procedures were identified, respectively. In the preimplementation period, 278 (57%) procedures were compliant with all documentation, vs. the postimplementation period, where 287 (71%) procedures were compliant (p < 0.001). ConclusionImplementing an invasive procedure documentation infographic and direct feedback improved overall documentation compliance for nonemergent invasive procedures.

An evaluation of documentation and follow-up on the use of SBIRT in an outpatient behavioral health clinic through the use of the CRAFFT tool.

Substance use among adolescents continues to present as a public health concern. Screening, Brief Intervention and Referral to Treatment (SBIRT) is an effective process that has been proven to identify, reduce, and prevent at-risk use of substances when appropriately applied. The CRAFFT tool is an evidence-based screen used to identify substance use in adolescents aged 12-21 years of age. The purpose of this project is to assess the rates of substance use in the adolescent population at a behavioral health clinic through the CRAFFT tool while also assessing for provider documentation compliance and overall revenue benefits of SBIRT. A retrospective chart review was used for this practice evaluation. Descriptive statistics were used through assessing frequencies and averages to gain insight not only on the rates of at-risk substance use and documentation compliance, but also on psychiatric diagnoses and medication regimens. Three hundred and forty-one patient encounters were reviewed over a 3-month period. Of these 341 encounters, 63.6% of the visits were in-person and 36.4% were conducted virtually. 72.4% of patient encounters had no documented CRAFFT screen, yet 31% of completed CRAFFT screens were positive for substance use or misuse. For those encounters with no completed CRAFFT screen documented, there was an estimated lost income for potential billings at a rate of $33.41 per encounter for a total of $8252.27. Substance use and misuse in adolescents continues to exist as a public health concern. The CRAFFT tool can be a feasible means of screening for substance use in adolescents when consistently and longitudinally incorporated.

Fostering Oral Chemotherapy Understanding and Safety (FOCUS) Project: Interventions for improving knowledge and compliance with national safety standards.

370 Background: Oral chemotherapy drugs are not always subject to the same safety standards as intravenous chemotherapy. Variability in safety practices can cause gaps in care, creating a need for continuous review of this process. This quality improvement (QI) project sought to improve provider and staff general knowledge on oral chemotherapy and on national safety standards through an educational intervention and to evaluate the implementation of an electronic medical record (EMR) integrated chemotherapy documentation template geared towards improving compliance with national safety standards pertinent to oral treatment. Methods: We used a pre/post-test design to compare knowledge following an educational session. A 15-question test covering national guidelines and safety standards relevant to oral chemotherapy were used to evaluate base knowledge before and after the session. We compared pre and post-test scores using paired t-tests. Then, a chemotherapy documentation template was developed in the EMR. The medical records of 44 patients at the center were reviewed four months before and 44 patients one month after the template’s introduction and documentation compliance was assessed using 24 national chemotherapy administration safety standards from the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative and the 2016 ASCO/Oncology Nursing Society Chemotherapy Administration Safety Standards. Comparison of compliance rates were performed using independent t-tests. Results: A total of 65 providers and staff participated in the educational session and completed both the pre and post-test. There was a statistical significance in knowledge gained from pre-test to post-test (p value of &lt; 0.001). Additionally, from the 88 charts reviewed, there was a statistical improvement in compliance with national safety standards (p value of &lt; 0.001). The participants (n = 29) also scored the documentation template as above average indicating overall ease of use and feasibility for continued use. Conclusions: This QI initiative improved provider knowledge and compliance with oral chemotherapy national safety standards. As a result, more centers should focus efforts on awareness and utilization of established national safety guidelines; critical to addressing the disparities in practice. Additionally, having a standardized workflow that prompts documentation within the EMR and discussion of the national standards is key to quality and safe practice.

10. Russian Federation

In the follow-up to the Governmental Regulation of 9 July (<Документы – Правительство России) that endorsed accession of the 2007 Russian Federation to the Nairobi International Convention on the Removal of Wrecks (Nairobi Convention), a federal law (Law no. 395-FZ of 6 December), formalized the accession. The law includes for a reservation not to be bound by clauses 2 and 3 of Article 15 (Settlement of Disputes). The law also contains a notification about extending the application of the Nairobi Convention to its territorial sea as per clause 2 of Article 3 of the convention (<http://www.en.kremlin.ru/acts/news/67293>). In implementing the international commitments under the Nairobi Convention, necessary amendments to the domestic law were introduced by Federal Law no. 470-FZ, dated 30 December. In particular, the Merchant Shipping Code generally prohibits sinking of ships or their wrecks within the internal marine waters, territorial sea, and exclusive economic zone (<https://www.wto.org/english/thewto_e/acc_e/rus_e/WTACCRUS33A1_LEG_15.pdf>). Sunk or stranded ships, except for warships, shall be subject to removal. Under its new Chapter VII, a ship owner or a ship operator shall be obliged to report to a master of the nearest sea trading port the sunk wreck(s) with indications of circumstances and details as required by the convention. The right to report is also afforded to any person in the form of mere notification. Copies of such reports shall be transferred to the government of the Russian Federation, governments of affected federal regions, and to the states where the ship is registered. On the basis of these reports, relevant Russian governments shall take a decision to either remove a wreck or confirm absence of an environmental hazard. A ship owner shall be obliged to remove a wreck within established terms depending on the type of hazard (within three months, should the wreck pose a hazard to navigation or the marine environment, or six months, if there is a hazard to fishing or hydro-technical constructions) after notification of the sea trading port and in conformity with removal compliance documentation. Should this not be done, wrecks shall be removed by a relevant sea trading port or by the government of the nearest federal region. The latter are entitled to require compensation of costs from an insurance company. A ship owner who omits an obligation to provide a removal compliance documents shall be released from the ownership right that may be reinstated upon a judicial ruling.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

O41 - Is the partogram still relevant? Findings of a randomised trial comparing two partogram designs for monitoring active labour progress in low risk women

Partograms with visual prompts such as Action lines are universally used to monitor labour progress. The Action line assumes a minimum rate of cervical dilation in the active phase of labour of 1 cm per hour. However, recent studies have demonstrated that normal labour progression is very variable and new partograms have been design to account for normal variations in progress with the use of a ‘Dystocia’ line. Correct commencement and use of any partogram is essential for utility in indicating labour dystocia. To compare two designs of partograms for compliance in documentation and use for managing labour. We randomised 228 low risk nulliparous women at term in spontaneous labour to a partogram with either an Action line (control) or Dystocia Line (intervention). Primary outcome was the proportion of partograms commenced correctly. Secondary outcomes included correct application of the partograms accompanying clinical management protocol and labour and birth outcomes. Compliance rates for correct commencement and utilisation by clinicians of the assigned partogram was poor in both groups. While rates of augmentation by artificial rupture of membranes were significantly lower in the Dystocia Line group there were no other differences in labour management or birth outcomes. There was little evidence that either partogram was being used correctly to document labour progress or the visual prompts of an Action or Dystocia line being considered in the assessment and management of prolonged labour. The use of centralised monitoring of labour progress may have been a contributing factor.

393 Communication in Catheter Care: A Closed Loop Audit of Catheter Documentation in Emergency Presentations to a Tertiary Urology Centre

Abstract Aim Estimates suggest that 20% of patients admitted to hospital undergo catheterisation, some of whom will end up discharged with catheters. Clear documentation assists in communication between hospital and community teams. The EAUN has identified key areas for documentation including use of care plans. We audited compliance with documentation pre- and post-intervention in a tertiary urology department Method Emergency patients presenting to urology were identified over a 3-week period pre-intervention and 3-weeks post-intervention. Clinical notes were audited for documentation of catheterisation. Domains assessed included indication, type/size of catheter, catheter balloon volume, residual volume, urinalysis, and plan. Use of care plans was also audited. Intervention involved development and deployment of a poster as well as discussion with staff. Results In total 274 patients were identified. 47 catheters were inserted pre-intervention, with variable compliance in documentation throughout the domains with similar pattern of compliance noted in the post-intervention group (n=42). Compliance was highest in size of catheter and indication for insertion, with urinalysis the most frequently missed domain (14.9% pre-intervention, 9.5% post-intervention). The only area with significant improvement was documentation of balloon volume (p=0.0019). Use of the care plan showed some minor improvement but was generally poor. Conclusion Use of visual cues did not result in approvement in documentation. Discussion with the teams suggested awareness of the domains and care plan however, they didn't necessarily think of them at time of documentation. As such a text prompt for the electronic notes is now in development and further audit to assess impact pending.

742 Quality of Operative Notes for Renal Transplant Surgery - Is Our Documentation Satisfactory?

Abstract Introduction Operation notes are essential in providing details of the procedure undertaken. The Royal College of Surgeons (RCS) Good Surgical Practice (GSP) guidelines recommend a checklist of 18 documentation items. Although these guidelines are useful, their broad and non-specific nature provides limitations to fields like transplantation, where additional information is needed. Ghoneima et al recommended transplant specific GSP checklist of 32 criteria for operation notes in transplantation. Our aim is to evaluate renal transplantation operation notes against these criteria. Method A retrospective audit of renal transplant operation notes was undertaken within Cardiff Transplant Unit between October 2020–2021. Notes were reviewed against new transplant specific GSP checklist. Results A total of 85 renal transplants were performed by 8 Consultant Surgeons. Sixty-two (73%) operation notes were hand-written and 23 (27%) electronically typed. Eleven standards had documentation compliance of &amp;gt;95% (e.g., date, surgeons’ names, recipient blood vessels, incision, allograft vascular anatomy, perfusion timings, closure, signature, etc). Some important transplant-specific information (e.g., primary renal disease, details of current renal replacement therapy, reperfusion characteristics, donor details (e.g., age, comorbidities), HLA mismatch, prosthesis (ureteric stent) details) were poorly documented (0–27% documentation compliance). Antibiotic and DVT prophylaxis documentation was also very poor (1–30%). Post-operative instructions did not record target blood pressure (0%) and postoperative potassium and ultrasound scan instructions were recorded in 65% of notes. Discussion Clear documentation is important for good surgical practice. This study highlights the need for a transplant-specific operation notes template, to not only improve the documentation but to standardize the key information recorded for every transplant performed.

978 Evaluation of the Quality of Our Consent Forms Used for Ureteroscopy and Nephroureteroscopy - Is It Time to Go Digital?

Abstract Aim Consent documentation for surgical procedures must be precise and clear in order to achieve excellence in clinical practice. In this audit, we aim to compare our consent forms against BAUS information leaflets on ureteroscopy and stone procedure and assess the documentation of all serious and frequently occurring complications as mentioned on BAUS leaflet. Method We retrospectively reviewed the consent forms of 60 patients who underwent elective ureteroscopy between August 2020 - April 2021 to assess the quality of documentation as well as legibility of handwriting. Results As a total of 60 consent forms were reviewed. 35 males and 25 females contributed to the study with 59 being the median age. There were over 10 risks being commonly missed. Some of the important risks such as stone recurrence 95%, catheterisation 92%, major damage to ureter wall 86%, pain 71% and residual stone 61% were missed. The documentation also outlines other risks; ureteric stricture 53%, aesthetic risk 67%, failure to access ureter 51% and stent symptoms 47%. Minor damage to the wall of ureter 41%, alongside need of another surgery were recorded as other commonly neglected risks. However, only 7% of the consent forms did not mention bleeding and just 2% of the forms failed to include stent insertion as a common effect of procedure. Only 17% consent for did not have eligible handwriting, although this is subjective. Conclusions Documentation on consent forms for ureteroscopy lacks accuracy and missed important information. We propose use of digital consent form to assess compliance and quality of consent documentation.

50 A Closed-Loop Clinical Audit on Surgical Documentation at a Tertiary Level Hospital in India: Where Do We Stand?

Abstract Aim To perform an audit to check Quality &amp; Compliance of Surgical documentation using STAR Score at a tertiary hospital in India. Method A total of 90 case files were studied and assessed in detail from all surgical departments. The audit was done for a period of 1 month at a tertiary hospital in India. The “STAR: Surgical tool for auditing records” tool was used to collect data accordingly. The results were then compared with standard guidelines and analyzed. A series of departmental training and implementation meetings were carried out. After 2 weeks, a re-audit was performed. Result The overall compliance score of the hospital was found to be 74%. Departments of General surgery and orthopedics showed a higher rate of compliance, each constituting 82% while the Department of Neurosurgery showed the least compliance of 62%. It was also seen that the maximum percentage of missing information consisted of anesthetic records and subsequent entries. After the re-audit, a considerable improvement was observed, with the compliance rate improving to 90% in all departments. Conclusion We believe that compliance and implementation of the STAR Score is mandatory, as it can significantly improve the quality of documentation and can be implemented universally.

975 Evaluation of the Quality of Our Consent Forms Used for Ureteroscopy and Nephroureteroscopy - Is It Time to Go Digital?

Abstract Aim Consent documentation for surgical procedures must be precise and clear in order to achieve excellence in clinical practice. In this audit, we aim to compare our consent forms against BAUS information leaflets on ureteroscopy and stone procedure and assess the documentation of all serious and frequently occurring complications as mentioned on BAUS leaflet. Method We retrospectively reviewed the consent forms of 60 patients who underwent elective ureteroscopy between August 2020 - April 2021 to assess the quality of documentation as well as legibility of handwriting. Results As a total of 60 consent forms were reviewed. 35 males and 25 females contributed to the study with 59 being the median age. There were over 10 risks being commonly missed. Some of the important risks such as stone recurrence 95%, catheterisation 92%, major damage to ureter wall 86%, pain 71% and residual stone 61% were missed. The documentation also outlines other risks; ureteric stricture 53%, aesthetic risk 67%, failure to access ureter 51% and stent symptoms 47%. Minor damage to the wall of ureter 41%, alongside need of another surgery were recorded as other commonly neglected risks. However, only 7% of the consent forms did not mention bleeding and just 2% of the forms failed to include stent insertion as a common effect of procedure. Only 17% consent for did not have eligible handwriting, although this is subjective. Conclusions Documentation on consent forms for ureteroscopy lacks accuracy and missed important information. We propose use of digital consent form to assess compliance and quality of consent documentation.

EP-271 Assessing the Impact of Implementing the STAR Score at a Tertiary Level Hospital in India: A Closed-loop Clinical Audit

Abstract Aim To perform an audit to check Quality &amp; Compliance of Surgical documentation using STAR Score in the general surgery department of a tertiary hospital in India. Method A total of 20 case files were studied and assessed in detail from the general surgery department. The audit was done for a period of 1 month at a tertiary hospital in India. The “STAR: Surgical tool for auditing records” tool was used to collect data accordingly. The results were compared with standard guidelines and further analyzed. Interventions were carried out by a series of departmental training and meetings. After 2 weeks, a re-audit was performed. Result The overall compliance score of the general surgery department was seen to be 82% in the first cycle. While the initial clerking constituted 21% compliance, operative records, and discharge summaries, showed compliance of 33% and 22% respectively. Consent and Anesthetic records showed the least compliance of 7% and 14%. The highest compliance was seen in subsequent entries, constituting 35%. In the second cycle, a significant change was reported as the overall compliance score increased to 95%. All sections showed a statistically significant increase. Consent and anesthetic records demonstrated an increase of 75% and 70% compliance, respectively. Conclusion We believe that compliance and implementation of the STAR Score is mandatory, as it can significantly improve the quality of documentation and can be implemented universally.

EP-250 A closed-loop clinical audit on the impact of implementing the STAR Score at a tertiary level hospital in India: Where do we stand?

Abstract Aim To perform an audit to check Quality &amp; Compliance of Surgical documentation using STAR Score at a tertiary hospital in India. Method A total of 90 case files were studied and assessed in detail from all surgical departments. The audit was done for a period of 1 month at a tertiary hospital in India. The “STAR: Surgical tool for auditing records” tool was used to collect data accordingly. The results were compared with standard guidelines and further analyzed. A series of departmental training and implementation meetings were carried out. After 2 weeks, a re-audit was performed. Result The overall compliance score of the hospital was found to be 74%. While the departments of General surgery and orthopaedics showed a higher rate of compliance, each constituting 82%, Neurosurgery showed the least compliance of 62%. It was also seen that the maximum percentage of missing information constituted of anaesthetic records and subsequent entries. After the re-audit, a considerable improvement was observed, with the compliance rate improving to 90% in all departments. Conclusion We believe that compliance and implementation of the STAR Score is mandatory, as it can significantly improve the quality of documentation and can be implemented universally.

Debunking the Myths of PACU Nursing Documentation

<h3>Background Information</h3> Weekly auditing of PACU documentation revealed inconsistencies in documentation practices among Post Anesthesia Care Unit (PACU) nurses. The individual preferences in documentation caused difficulty in retrieving data during chart review and auditing. Opportunities for standardizing documentation of nursing assessment, nursing care plan, medication administration and vital signs were identified in all PACU areas. The department identified the need to provide education on documentation accuracy, while regularly monitoring and evaluating documentation compliance. A decision was made to formulate a committee to standardize the auditing process, in order to sustain the compliance benchmark. <h3>Objectives of Project</h3> The goal of this project was to improve overall PACU documentation compliance by June 2021. The focus was to increase documentation compliance by 10% in the identified categories. The overall aim was to achieve documentation compliance of 90% in all PACU areas and have long-term sustainability. <h3>Process of Implementation</h3> •A PACU documentation committee was formed using Informatics Resource Nurses from inpatient, transitional, outpatient and out of OR PACU. The selection process involved self-nomination and leadership recommendation. •The documentation committee worked with the leadership team to develop unit-based reeducation and skills check-off to standardize documentation practices in all PACU areas. •A focused chart audit was created, and committee members conducted at least one audit per RN per month in all PACU areas. •A Peer-to-Peer Feedback Form was developed to provide real-time feedback and education to staff. •Chart Audit results were discussed in staff meetings with highlighted examples. <h3>Statement of Successful Practice</h3> •Data retrieved over the last 12 months showed significant improvement in standardizing PACU documentation and sustaining the documentation compliance above 90% in all areas. •Reeducation and skills check off helped standardize the practice and improved staff efficiency in documentation. •Review of the audit tool, guidelines for auditing and monthly meetings enhanced committee members' engagement and satisfaction. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Streamlining documentation expectations can improve documentation practices and sustain compliance. Some best practices include: •Training new nurses during orientation with auditors to show documentation expectations. •Develop a checklist for Nurses to ensure complete documentation and use as a resource at bedside. •Reward best practice by recognizing 100% compliance in monthly audits.

From Old to New: Process of Integrating PACU Phase 1 Documentation and Workflow from Old Electronic Health Record (EHR) System to New Electronic Health Record (EHR) System

<h3>Background Information</h3> In 2019, a new Electronic Health Record (EHR) was implemented to standardize and streamline access of patient health records across the health care system. Meaningful use of EHR provides benefits such as safety, quality, and efficiency in patient-care delivery. The adoption of the new EHR system has created significant disruption in the complex workflow of busy units, as well as frustration to users specifically in the usability functions of the new EHR system. This project will outline strategies and processes to ensure that resources are equipped to handle its complexity by employing methods to assist user for seamless transition from an old EHR system to new EHR system in phase 1 PACU. <h3>Objectives of Project</h3> •Identify and create a framework of key elements to bridge the gap in nursing documentation •Provide educational tools focusing on the change in workflow and documentation of clinical pathways •Create an audit tool to address nursing documentation compliance <h3>Process of Implementation</h3> Identified super users to serve as unit resources. Staff training included mandatory learning modules, post-tests, and unlimited practice simulations. All PACU workflow and clinical pathways were reviewed and revised to ensure the necessary "must haves" were included in the new platform. Created tip sheets of new workflow processes. An audit tool was created to address nursing compliance issues and cover key elements of workflow and documentation of clinical pathways. Leveraged use of lean methodology through daily huddle discussion of issues and generating ideas. <h3>Statement of Successful Practice</h3> The goals of the EHR implementation were achieved by familiarizing users with the new system through education, hands-on training, and constant follow through via lean methodology. Success was measured by rate of resolution of issues which achieved 100% by February 2020. Completion rate of RN documentation audits exceeded the set goal by 12.4%. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Providing the appropriate education and hands-on training served as of great value for successful implementation. The tip sheets created by the team improved effectiveness of user workflow and was spread to several PACU facilities within the healthcare system & vendor for their education and training.