Documenting the Nursing Process: A Community Based Participative Research Study

Abstract

This community based participative research (CBPR) study evaluated the Joint Commission (TJC) required nursing process documentation in the electronic medical records for patients at Wahiawa General Hospitals (WGH). The study’s research question asked the following: Did 1 on 1 education improve documentation of the nursing process in electronic health records? Quantitative data was collected over the course of one year that included preeducation baseline data and post-education data. Pre-education data was taken from medical records during the months of November 2013 to January 2014 for patients who had targeted diagnoses using WGH'S care-plan audit tool. Post-education data collection took place from mid March 2014 to the second week of July 2014. A total of 30 charts each month (5 charts from the ICU, 10 charts from the telemetry unit, and 15 charts from the Medical surgical unit) were used for pre-intervention baseline data collection. Diagnoses targeted for chart review included the following: Congestive heart failure (CHF), pneumonia, sepsis, diabetic ketoacidosis (DKA), chronic obstructive pulmonary disease (COPD), acute myocardial infarction (AMI) or cellulitis. These 7 diagnoses were chosen due to the high frequency and high risk of these diagnoses for the population served by WGH. Descriptive and inferential statistics were utilized to analyze study data. It was hoped that findings from this research result in an improvement in nurses compliance with the nursing process in documentation, thus improving care as well as compliance with federally mandated documentation procedures.