The Sutherland Clinical Assessment and Nursing Documentation (SCAND) project aims to improve the inconsistency of nursing documentation across Sutherland Hospital, focusing on the importance of clinical assessment in nursing.
This goal is to consistently communicate nurse findings and actions through documentation in a patient’s healthcare record.
By July 2019: 90% of nursing clinical documentation will consistently include a story, assessment and plan during each shift.
- Consistency in nursing documentation across the organisation.
- Improved nursing assessment skills.
- The provision of a clear framework for nurses to practice within.
- Increased patient safety as a result of organisation-wide improvement in communication, both written and verbal.
Nursing documentation in Sutherland Hospital is currently governed by a universal district policy that covers all documentation included in a patient’s health care record.
Following an audit of nursing documentation, inconsistency was found between documentation processes. These inconsistencies included timing, content and format of documentation. The audit also revealed that nursing documentation often missed the action/outcome component and was task-focused. Task-focused documentation focuses on one specific task rather than a holistic assessment and approach to the patient’s condition.
Since the roll out of Electronic Medical Record 2 (eMR2) in December 2017, Sutherland Hospital uses a hybrid system for health care records, as not all forms are currently electronically available. The hybrid system of paper and electronic records causes additional confusion about paperwork and documentation requirements for nurses. This sometimes results in missed and/or duplicated information.
There has also been an increased number of incidents reported on the Incident Information Management System (IIMS) which related to inconsistent clinical documentation. This includes Severity Assessment Code 2 investigations, which highlights inconsistent documentation as an ongoing theme.
- An organisation-wide survey was run by nurses to gain some insight into the culture of nursing documentation at Sutherland Hospital.
- These insights have informed a team-led pilot program, designed to work through barriers identified in survey and conduct small tests around proposed changes.
- The pilot trials different shift times where documentation is required to be completed and uses a template for documentation that guides the clinician through Story, Assessment (A-H) and Plan. This approach guides the clinician through a thorough and systematic approach to clinical documentation.
- In using this framework for nursing documentation, it helps to provide a consistent approach to how clinical documentation is to be completed.
Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.
- Started: May 2018
- Complete: July 2019
The project is currently being piloted across three wards in Sutherland Hospital. They are Radius, Gunyah and Cooinda wards.
Clinical Excellence Commission Clinical Leadership Program
As this project is still in implementation stages there is no evaluation or results to display as yet. The team plans to measure results through:
- tracking IIMS related to documentation
- auditing healthcare records
- conducting staff surveys.
- Ensure that the framework chosen is applicable to all specialties.
- As long as a hybrid system for health care records remains, consistent documentation will continue to be a challenge.
- Akhu-Zaheya L, et al. 2017, Quality of nursing documentation: Paper-based health records versus electronic-based health records, Journal of Clinical Nursing, Vol 27, Pg 578-589, John Wiley & Sons, Jordan.
- Blair W, Smith B. 2012, Nursing Documentation: Framework and Barriers, Contemporary Nurse, Vol 41, No 2, Pg 160-168, eContent Management Pty Ltd.
- Okaisu E, et al. 2016, Erratum: Improving the quality of nursing documentation: An action research project, Curationis, Vol 38 No 2, University of Cape Town, South Africa
- Olgers TJ, et al. 2017, The ABCDE primary assessment in the emergency department in medically ill patients: an observational pilot study, The Netherlands Journal of Medicine, Vol 75, No. 3, Van Zuiden Communications B.V, Netherlands.
- Thim T, et al. 2012, Initial assessment and treatment with the Airway, Breathing Circulation, Disability, Exposure (ABCDE) approach, International Journal of General Medicine, Vol 5, Pg 117-121, Dove Press, Denmark.
- Tranter S. 2009, A hospital wide nursing documentation project, Australian Nursing Journal, Vol 17, No 5, Sydney, Australia.
Clinical Nurse Consultant, Critical Care Medicine
South Eastern Sydney Local Health District
Phone: 0431 849 356
Nurse Manager- Leadership Development Facilitator
Nursing & Midwifery Practice & Workforce Unit
South Eastern Sydney Local Health District
Phone: 02 9540 8270