This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
This systematic review attempts to answer the following question – which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting?
A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020.
Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles.
The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance.
Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020.
Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%.
Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.
Keywords: nursing documentation, hospitals, quality improvement, systematic reviewClinical documentation is the process of creating a written or electronic record that describes a patient's history and the care given to a patient (Blair & Smith, 2012; Wilbanks et al., 2016). It serves as an important communication tool for the exchange of information between healthcare providers and it is stored in a printed or electronic medical record (Duclos-Miller, 2016; Mishra et al., 2009). According to Wilbanks et al. (2016) good quality documentation has been defined as documentation that is correct and comprehensive, uses clear terminology, is legible and readable, timely, concise and plausible.
Poor nursing documentation in the acute care setting may have negative impacts on patient outcomes and may also result in litigation (Duclos-Miller, 2016). Therefore it is important to determine if there are any strategies that will provide meaningful improvements in the quality of nursing documentation in the acute care setting.
At the time of writing there were four systematic reviews related to nursing documentation. Three (Johnson et al., 2018; Müller-Staub et al., 2006; Saranto et al., 2014) examined the impacts of standardized nursing languages (SNL) on the quality of nursing documentation. They were narrative reviews, and include studies that were not necessarily confined to the acute sector. They demonstrated that SNL will improve the quality of nursing documentation, assist in the fulfilment of the legal requirements of documentation and facilitate the use of an electronic health record (EHR). One systematic review (McCarthy et al., 2019) examined the effects of electronic nursing documentation and found that utilizing an END system could improve the quality of nursing documentation, decrease documentation errors and increase compliance with nursing documentation guidelines.
These systematic reviews were narrative in structure and no attempt has been made to determine if the improvement in each of the studies reviewed is a clinically meaningful improvement. The aim of this systematic review is to qualitatively and quantitatively analyze the literature in an attempt to determine which strategies to improve compliance with clinical nursing documentation guidelines, and improve the quality of nursing documentation, have been most effective in the acute setting.
A systematic review of the literature was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines, where possible.(Page et al., 2021a, b)
A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and again October 2020, due to the time that had elapsed. The only limitations were for articles in peer reviewed journals that were written in English. An analysis of the text words contained in the titles, abstracts and index terms found in relevant articles was used to inform the search strategy. The reference lists of articles selected for inclusion were hand searched for additional articles. The full search strategy for CINAHL is found in Appendix 1.
Studies were included if they were quantitative research investigating strategies to improve clinical nursing documentation in acute hospitals. Where possible, the quantitative components of mixed method studies were also included. The nursing documentation components of studies that also involved allied health or medical documentation were included where possible. Studies were not excluded by intervention, we attempted to include as many studies as possible (See Table 1 ).
Inclusion and Exclusion Criteria.
| Included | Excluded | |
|---|---|---|
| Population | Clinical nursing documentation in acute hospitals – care plans, flow sheets, nursing assessment, observations, diagnosis, interventions, outcomes, discharge summaries, patient education, adverse drug reactions | Allied health, doctors, students, complimentary health, chaplains, dentists, primary care, residential care, palliative care, community care, clinical coding, trauma registers, incident reports, medication charts |
| Intervention | Strategies to improve clinical nursing documentation e.g. education, EHR, SNL, clinical governance, process improvement, audit and feedback, form modification | Nil |
| Outcome | Quantifiable changes in the quality of clinical nursing documentation | Changes in the quality of nursing documentation that are not quantifiable |
| Study type | Quantitative studies – Randomized Controlled Trials (RCT), and quasi experimental studies e.g. before and after, cross section, Plan Do Study Act (PDSA) time series analysis, randomized trials; that are published in English in a peer reviewed journal; the quantitative components of mixed method studies. | Qualitative studies, studies in a language other than English, studies not published in a peer reviewed journal. |
Abstract and title screening from the database results lists was initially performed by the principal reviewer and citations were downloaded into EndNote X9 if they appeared relevant. The abstracts in EndNote were then screened independently by both reviewers and conflicts were resolved by discussion. Full text screening was undertaken by the principal reviewer.
A Summary of Data (SOD) excel spreadsheet was prepared by the principal reviewer. For each study that met the selection criteria the following data were extracted - author, year of publication, country of origin, study title, aims, study design, setting, sample size, method of randomization, interventions used, instruments used to collect data, statistical analyzes performed, outcome measures, results and conclusions.
Studies included in this systematic review were quasi-experimental studies and were appraised for risk of bias by the principal reviewer using the JBI critical appraisal for quasi-experimental studies (Tufanaru et al., 2017). The JBI Critical Appraisal Checklist for Randomized Controlled Trials (Tufanaru et al., 2017) was used for the only RCT included in the review. For before and after studies, the pre intervention group was not considered to be a control group. The statistical analyzes performed in the studies were evaluated for appropriateness with reference to the Flow chart for hypothesis tests, categorical and numerical data, found on the back inside cover of Medical Statistics at a Glance by Petrie and Sabin (2020)
Rating the certainty of the evidence was undertaken using the principles of GRADE when a meta-analysis has not been performed (Murad et al., 2017)
The analysis was performed by the principal reviewer. Where possible each study was quantitatively analyzed such that the data collected in each study were used to calculate a pre intervention and a post intervention percentage compliance score i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD excel and used as a basis for comparison between the studies.
For each study, a meaningful compliance rate was defined as a post intervention compliance rate ≥ 70%, using the definition of compliance as defined within the study . This was chosen as it seems a satisfactory return on investment for the time, effort and resources that are often expended to improve nursing compliance with clinical documentation.
Each study was analyzed thematically in terms of the intervention strategies used. The themes were education alone, audit and feedback, EHR versus paper health record, SNL, EHR modifications, new forms, guidelines, and system changes. Each study was coded according to all of the intervention strategies that were applied, and the codes were recorded on the SOD spreadsheet. See Table 2 for a definition of each of the themes.
Definition of the Themes.
| Education alone | Training sessions, handouts, instructional emails, quizzes, prompt cards, meetings, coaching, awareness raising, elearning, simulation, workshops, champions, orientation |
| Audit and feedback | Paper or EHR documentation audits with general feedback or personal feedback to nurses |
| EHR vs paper record | Electronic health records, eDisharge applications, computer generated care plans, computerized patient assessment - compared to equivalent paper based records. |
| SNL | Standardized nursing languages – North American Nursing Diagnosis Association (NANDA) nursing diagnoses; Nursing Interventions Classification (NIC); Nursing Outcomes Classification (NOC); VIPS (an acronym for well-being, integrity, prevention and safety); Problem Etiology Signs/Symptoms (PES) |
| EHR modifications | Enhancements in the EHR, triggers, prompts, automatic suggestions, reconfigurations to reduce the number of clicks, shortcuts, forced functions, hard stops, passive visual cues, mandatory fields, ability to import notes, automatic defaults |
| New forms | New or modified paper forms and new or modified EHR templates |
| Guidelines | Documentation guidelines, standard operating procedures, policies, protocols, standards |
| System changes | Provision of equipment, cohorting of patients, ward clerks checking notes for completion, a multidisciplinary approach, avoiding duplication of nursing notes, measurement Monday, mandating compliance |
This review is as a narrative synthesis with a quantitative component. For each of the thematic strategies, the post intervention compliance scores were compared to determine if any of the strategies were effective in achieving a meaningful improvement in the quality of nursing documentation. Studies that achieved large improvements in compliance from a very low initial compliance base may not have achieved a final compliance rate of ≥ 70%, therefore good performances may have been missed in this analysis. To compensate for this, studies that achieved an improvement of ≥ 50% were also identified and analyzed in terms of strategies employed.
Ethics approval was sought and was not required.
An initial search was performed in May 2019. Due to the time that had elapsed, a follow up search was performed in October 2020. See Figure 1 PRISMA Diagram below
PRISMA diagram for searches conducted in 2019 and again in 2020 due to the time that had elapsed
Studies were excluded after full text review if they did not meet the inclusion criteria for this study (see Table 1 ).
No studies were excluded after critical appraisal, we attempted to include as many studies as possible.
Seventy six full text articles were reviewed for this study. See Appendix 2 for The Summary of Data table. You can download the data in the SOD spreadsheet from here https://osf.io/8r49s/files/
Fifty seven of the studies were before and after studies, with the remainder being cross sectional studies (six), Plan Do Study Act studies (four), non-randomized controlled studies (four), time course analyzes (two), randomized trials (two) and one randomized controlled trial. Sixty six studies were conducted in western countries including the USA, Canada, Europe, the UK and Australia. The remainder were conducted in Jordan, Kenya, Brazil, Iran and Singapore. Publishing dates for the studies ranged from 1991 to 2020, all but seven of the studies were conducted in the last 20 years.
Nine of the studies included in this review used education as their only strategy to improve nursing compliance with clinical documentation (Cone et al., 1996; Finn, 1997; Griffiths et al., 2007; Jackson, 2010; Lieow et al., 2019; Linch et al., 2017; Müller-Staub et al., 2008; Mykkänen et al., 2012; Phillips et al., 2019). Of these studies, four had a post-intervention compliance rate ≥ 70% (Jackson, 2010; Lieow et al., 2019; Müller-Staub et al., 2008; Mykkänen et al., 2012).
When audit and feedback are combined with the use of a pre-existing EHR the results are also encouraging (Cline, 2016; Elliott, 2018; Esper & Walker, 2015; Gerdtz et al., 2013; Gloger et al., 2020; Hayter & Schaper, 2015; Hom et al., 2019; Jacobson et al., 2016; Kamath et al., 2011; Tejedor et al., 2013; Unaka et al., 2017). Ten of the 11 studies had a final compliance rate ≥ 70%.
Thirteen studies compared EHR with paper records as one of the strategies for increasing nursing documentation compliance (Akhu-Zaheya et al., 2018; Ammenwerth et al., 2001; Dahlstrom et al., 2011; Gunningberg et al., 2008; Gunningberg et al., 2009; Higuchi et al., 1999; Hübner et al., 2015; Larrabee et al., 2001; Mansfield et al., 2001; Rabelo-Silva et al., 2017; Rykkje, 2009; Thoroddsen et al., 2011; Tubaishat et al., 2015). Six of these studies demonstrated a final compliance rate ≥ 70% when an EHR was utilized. It should be noted that Larrabee et al. (2001) had a high compliance rate, however the improvement was 0.2%. Two studies, (Akhu-Zaheya et al., 2018; Rykkje, 2009) demonstrated a decline in compliance when comparing EHR to paper based records.
Twelve studies included changes to guidelines, procedures or policies as one of the strategies to improve nursing documentation (Considine et al., 2006; Elliott, 2018; Flores et al., 2020; Gordon et al., 2008; Gunningberg et al., 2008; Habich et al., 2012; Jacobson et al., 2016; Margonary et al., 2017; Mitchell et al., 2010; Nomura et al., 2018; Trad et al., 2019; Turner & Stephenson, 2015). Five of these studies achieved a final compliance rate ≥ 70% (Elliott, 2018; Flores et al., 2020; Gordon et al., 2008; Jacobson et al., 2016; Nomura et al., 2018). It should be noted that the results for Elliott (2018) must be used with caution as some negative results may have left out in the final calculation of compliance rates.
Thirty six studies achieved a meaningful compliance rate i.e. a post intervention compliance score ≥ 70%. Download Table 4 Compliance ≥ 70% from here https://osf.io/8r49s/files/
Seven of the studies had an improvement rate of ≥ 50% (Chineke et al., 2020; Gordon et al., 2008; Hayter & Schaper, 2015; Kamath et al., 2011; Müller-Staub et al., 2007; Porter, 1990; Unaka et al., 2017). The post intervention compliance rate was ≥ 80% for all of them, except Hayter and Schaper (2015), where the final compliance rate was 72%.
There are serious concerns regarding the certainty of the evidence, and the evidence has been graded as very low due to methodological limitations and issues with imprecision, inconsistency and publication bias (See Table 5 )
Certainty of Evidence.
| GRADE domain | Judgement | Concerns about certainty domains |
|---|---|---|
| Methodological limitations of the studies | There was one RCT, the remainder were quasi experimental. There was a large variations in sample sizes (n = 3 to n = 89,521). p values were not always calculated. Instruments to measure the outcomes were not always validated or tested for reliability. Only 3 of the studies had multiple pre-intervention measures. | Very serious |
| Indirectness | The settings, populations, interventions, outcomes and comparators all provide direct evidence to the question. | Not serious |
| Imprecision | The total number of notes audited was in the tens of thousands, however only two studies reported Confidence Intervals (CI), therefore it is not possible to adequately determine imprecision. | Serious |
| Inconsistency | The direction and magnitude of effect varied across the studies from small decreases in compliance to large improvements in compliance. | Serious |
| Publication bias | There was a comprehensive search and positive and negative results were published, however some relevant studies may have been missed due to the reviewers being unable to access the full text. | Serious |
Of the nine studies that used education alone as the strategy to improve nursing documentation, four resulted in a meaningful compliance rate. It was not possible to determine if the form of the education that was applied, e.g. lectures, simulation, case discussion or demonstrations, had any influence on the final outcome of documentation compliance. The number of studies was too small and the descriptions of the education supplied was not always adequate enough to draw any conclusions.
In terms of the hours devoted to education, one study, Müller-Staub et al. (2008), involved 22.5 h of education for a final compliance rate of 94.5%. However another study, Linch et al. (2017) had 30 h of instruction and discussion for a final compliance rate of 45%, therefore it is difficult to draw any conclusions as to whether the amount of time spent on education has any effect on documentation compliance. Bearing in mind the small number of studies that utilized education alone, it appears education alone will improve compliance, however it may not improve compliance to a meaningful extent.
When documentation auditing with personal or individual feedback was one of the strategies utilized, ten out of the 11 studies achieved a compliance rate of 70% or more (see Table 3 https://osf.io/8r49s/files/). This suggests that auditing and personal
feedback, combined with other context specific strategies such as education, new forms, new templates or EHR modifications, may be a reliable strategy for improving compliance. However the results for Elliott (2018) should be used with caution as some negative results may have been left out in the final calculation of compliance rates. When an EHR was used to conduct the audits, the improvement in compliance rate seems to be reliably high; ten out of the 11 studies that used an EHR to conduct the audits achieved a compliance rate of ≥ 70%. This may be due to the fact that the time consuming audit process is made more efficient by using an EHR for data extraction (Lieow et al., 2019).
Thirteen studies utilized an EHR as one of the strategies to improve nursing documentation, six of these achieved a meaningful compliance rate, however for one of these, Larrabee et al. (2001), the improvement was 0.2% It appears from these studies that introducing an EHR may not guarantee a meaningful improvement in nursing documentation, and it may even be counterproductive as shown by the studies Rykkje (2009) and Akhu-Zaheya et al. (2018). In nearly all of the studies the EHR system was not described or named therefore it was not possible to determine if the nature of the EHR had any effect on the results.
Standardized Nursing Language was used in ten studies, four of them achieved a compliance rate of ≥ 70%. The use of NANDA and NIC appears to be more effective than PES or VIPS for improving nursing documentation compliance. Four out of the six studies that used NANDA and NIC had a final compliance rate ≥ 80% (Larrabee et al., 2001; Müller-Staub et al., 2007; Thoroddsen et al., 2011; Thoroddsen & Ehnfors, 2007); however it should be remembered that Larrabee et al. (2001) had 0.2% improvement. Standardized Nursing Language will improve nursing documentation, however it may not improve to a meaningful extent.
Of the 10 studies that used EHR modification, seven achieved a meaningful compliance rate. For the purposes of this systematic review, new or reconfigured EHR templates, are included in the next section - New Forms. Many different EHR modifications were used across the various studies (see Table 2 ), and there are indications that prompts in the EHR may be useful in improving compliance, however there is no single modification that ensures meaningful compliance.
For the purposes of this systematic review new forms included new or modified paper forms and new or modified EHR templates. Thirty two of the studies included new forms as one of the strategies to improve nursing documentation, seventeen of these studies improved nursing documentation to a meaningful degree.
Of the 12 studies that used the creation of new guidelines or changes to existing guidelines as a strategy, five achieved a meaningful compliance rate. It appears that guidelines will improve nursing documentation but not always to a meaningful degree.
Ten studies utilized administrative or system changes as one of the strategies to improve compliance. The studies were too heterogeneous for any single strategy to be proven effective at providing a meaningful improvement. All of the studies that used system changes showed improved nursing documentation, six out of the ten studies demonstrated improvement to a meaningful degree.
In the future, issues with clinical nursing documentation may be dealt with by technological means, for example the use of digital scribes. Digital scribes will employ advances in speech recognition, natural language processing, artificial intelligence, machine learning and clinical decision support technologies, to translate clinical encounters into meaningful and accurate records (Coiera et al., 2018). However speech recognition systems and artificial intelligence will need to be vastly improved before the benefits outweigh the risks of using a digital scribe. Meanwhile strategies to improve nursing documentation remains a relevant topic for research.
Full text screening and the quantitative and thematic analyzes were performed by one reviewer, this may have caused some bias in the results. There was no funding for this systematic review, therefore full text access to all of the articles that appeared in the search results was not possible, this may have resulted in some relevant research not being included in the final analysis. The research articles that were analyzed in this project were very heterogeneous in terms of design, statistical analyzes and strategies employed, meaning that traditional systematic review meta-analysis was not possible, and the percentage analysis that was undertaken was rudimentary at best. Only data that could be converted to percentages were included, therefore some data were missed in the analysis.
The studies usually combined many strategies, making it difficult to tease out the effects of any single strategy. The time that elapsed between the intervention and the post intervention audits varied between the studies and was not analyzed in this systematic review. This may have disadvantaged the studies that used a longer time interval to determine if the improvements in documentation were sustained over time. The level of certainty of the evidence is very low, (see Table 5 ). These limitations could be overcome by a follow up study, focusing on audit and personal feedback and utilizing more rigorous statistical analyzes.
Documentation audits with personal feedback should be considered as one of the strategies to be utilized when attempts are made to improve the quality of nursing documentation.
Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in nursing clinical documentation. Utilizing an EHR to perform the audits may be beneficial to the process, by making the audit process more efficient. The certainty in the evidence is very low, therefore using audit and personal feedback as a strategy to improve clinical nursing documentation is an area that would benefit from more research.
| Search | Search terms | Results |
|---|---|---|
| S1 Improvement | Compliance OR clinical governance OR quality improvement OR strategies OR audit OR process improvement OR Clinical Governance OR Quality Improvement | 49,843 |
| S2 Nursing documentation | electronic medical records OR electronic health records OR Documentation OR patient notes OR medical notes OR medical records OR health records OR patient records OR progress notes OR discharge summar* OR care plans OR medication charts OR charting | 13,899 |
| S3 Nursing | Nurs* | 34,956 |
| S4 Hospital | hospital | 52,337 |
| S1 AND S2 AND S3 AND S4 | 243 |
Search limiters – Peer reviewed, in English. Date range: May 2019 - Oct 2020
| Author/year/country/title | Study design/sample | Strategies | Outcome measures | Results |
|---|---|---|---|---|
| Forberg, U/ 2012/ Sweden. Title - Accuracy in documentation of peripheral venous catheters in pediatric care: An intervention study in electronic patient records | Before and after study. A retrospective audit of notes before intervention (n = 54), at 4 months (n = 50) and 10 months (n = 37) post intervention. | 1. Standardized EHR template 2. Education | Percentage of notes with complete recording (date, size, side, size at insertion and removal) | Before: Insertion date = 77%, side = 63%, site = 80%, size = 40%, Insertion complete = 31%, removal complete = 0%, complete recording insertion and removal = 0%, any kind = 91%. After: insertion date = 76, side = 87%, site = 93%, size = 62%, insertion complete = 49%, removal complete = 9%, complete recording insertion and removal = 9%, any kind = 93%. |
| Phillips, M/2019/USA Title - Pain assessment documentation after opioid administration at a community teaching hospital | Before and after study. A retrospective audit of notes before intervention (n = 160) and post intervention (n = 160). | 1. Mandatory education | Frequency of documentation of pain scores within appropriate time frame after opioid administration and completed documentation of vital signs after opioid administration. | Frequency of documentation of pain scores within appropriate time frame after opioid administration- pre = 622/1890 administrations (32.9%), post = 547/1,446 (37.8%); Completed documentation of vital signs after opioid administration - pre = 0/1,890(0%), post = −0/1,446(0%). BP before = 12.1%, after = 13.2%; Heart Rate (HR) before = 12.0%, after = 13.1%; Temp before = 906%, after = 9.5%; Respiratory Rate (RR) before = 33.7%, after = 44.1%, sedation level before = 33.5%, after = 44.1% |
| Turner, A/2015/ Australia Title- Documentation of chemotherapy administration by nursing staff in inpatient and outpatient oncology/hematology settings: A best practice implementation project. | Before and after study. Baseline (n = 50) and follow up (n = 50) audit of notes. | 1. Development of documentation guidelines. 2. Education | Percentage compliance with 18 best practice audit criteria | Inpatients: improvements in 12/18 criteria; 2/18 criteria remained 100%; poorer compliance in 4/18 criteria; baseline average compliance across all criteria = 52.72%; average follow up compliance across all criteria = 63.06%. Outpatients: improvements in 10/18 criteria; 3/18 criteria unchanged at 98-100%; poorer compliance in 5/18 criteria; baseline average compliance across all criteria = 71.56%; average follow up compliance across all criteria = 74.89% |
| Porter, Y/1990/USA Title- Brief: Evaluation of nursing documentation of patient teaching | Design: Non randomized controlled trial; hospital wide baseline audit; monthly audits of the control and experimental groups during the study period. N = 150 charts audited monthly during the 4 month study. | Control group 1. Pre-printed care plan 2. Monthly audits. Experimental group - 1. Pre-printed care plan 2. Education, 3. monthly audits with feedback | The average number of charts that had teaching documented. | Hospital wide baseline average = 15% of nursing charts had teaching documented. Control group improved from 15% to 53%. Experimental group improved from 15% to 90% |
| Nost, T/2017/Norway Title- Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest-post-test study in a medical department in a university hospital. | Before and after study. Pre-test 1 year prior to intervention (n = 49). Post-test 1 month post intervention (n = 50) | 1. SNL nursing diagnoses in PES format 2. Education | Mean scores | Pre-test mean score for nursing diagnosis: quantity = 1.19/3, quality = 1.15/3; post-test mean score for nursing diagnosis: quantity 2.49/3, quality = 1.65/3. Pre-test 3/3 score for quantity = 6.1%, for quality = 0%; post-test 3/3 score for quantity = 62%, for quality = 4%. |
| Hospodar, M/2007/ USA Title- Sticking together! A creative approach to documenting insulin double checks | Before and after study. Baseline prior to implementation (n = 187). Re test 4 weeks into implementation (n = 230). | 1. A Sticker that can be signed and added to the chart. 2. Education | Total insulin administrations against administrations with double check | Pre intervention 65/187 = 35%. Post intervention 167/230 = 73% |
| Florin, J/2005/Sweden Title- Quality of nursing diagnoses: Evaluation of an educational intervention. | Before and after study. Retrospective pre-test/post-test with a non-equivalent control group. Patient records were selected from a 3 month period before (n = 70) and after (n = 70) the intervention | 1. Education. 2. A new form | Changes in quality/quantity between pre and post tests and between the intervention and control groups as measured by CAT-CH_ING and the Quality of Nursing Diagnosis scale (QOD) | Experimental- in the experimental unit nursing diagnoses were documented in 34% of records pre and 69% post intervention. QOD for experimental -mean diagnostic score improved from pre = 6.5/14 to post = 8.8/14; QOD control mean - diagnostic score was unchanged with pre = 4.3/14 to post = 4.4/14. CAT-CH-ING experimental - mean quantity and quality increased from pre = 1.5/6 to post = 3.1/6; CAT-CH_ING control - mean quantity and quality was unchanged pre = 0.0/6 to post = 0.1/6. |
| Bernick, L/1994/ Canada Title- Nursing documentation: A program to promote and sustain improvement | Before and after study. Pre-test/post-test audit of progress notes. pre-test audit n = 28, 1 month audit n = 43, 2 months n = 44, 3 months n = 27, 4 months n = 31 | 1. Education 2. Note audits with personal and group feedback. | Analysis was based on the number of criteria not met (errors per progress note) | Mean errors per notes by nursing unit - Unit A - pre = 8.50/35, 1 month = 4.39/34, 2 months = 4.00/35, 3 months = 3.00/35, 4 months = 2.80/35 Unit B - pre = 8.82/35, 1 month = 6.04/35, 2 months = 4.64/35, 3 months = 3.38/35, 4 months = 2.05/35 |
| Finn, L/1997/UK Title- Nurses’ documentation of infection control precautions: 2 | Before and after study. Pre-test/post-test with unmatched samples. Pre-test audit n = 17; post-test audit n = 50. | 1. Education | Percentage compliance with documentation for each item on the instrument. | Pre-test: infection recorded = 23.5%; hand hygiene recorded = 23.5%; protective clothing recorded = 23.5%; decontamination recorded = 11.8%. Post-test: infection recorded = 64.0%; hand hygiene = 32.0%; protective clothing = 42.0%; decontamination = 24.0%. |
| Unaka, N/2017/USA Title- Improving the readability of pediatric hospital medicine discharge instructions | Sequential Plan-Do Study-Act cycles with weekly audits of D/I. 6 months pre intervention n = 166; 11 months intervention n = 713. | 1. Education 2. Templates in the EHR 3. Audit with group and personal feedback | Percentage of D/I at or below 7th grade level, percent of discharge instructions written with a template. | The percentage of D/I written at or below 7th grade readability increased from a mean of 13% to more than 80% in 3 months; The mean was sustained above 90% for 10 months and at 98% for the last 4 months. The average reading level decreased from 10th grade to the 6th grade. The use of templates increased from 0% to 96% and was associated with the largest impact of overall improvements. |
| Tubaishat, A/ 2015/ Jordan Title- Electronic versus paper records: documentation of pressure ulcer data. | A cross-sectional, descriptive, comparative design with a retrospective review of patient records. Hospital using EHR n = 52 records reviewed; Hospital using PR n = 55 records reviewed. | 1. paper record vs electronic health record | Accuracy- congruence between skin inspection and documentation. Completeness- presence of complete documentation i.e. size, grade, location, risk assessment, prevention. | Accuracy: Electronic Health Records (EHRs) = 43/52 (83%) had Pressure Ulcer (PU) documentation; Paper Records (PRs) = 39/55 (71%) had PU documentation. Completeness: for location EHR = 91% vs PR = 82%; for grade EHR = 88% vs PR = 72%; for size EHR = 79% vs PR = 49%; for risk assessment EHR = 81% vs PR = 44%; preventive devices EHR = 72% vs PR = 54%; repositioning EHR = 93% vs PR = 87%. |
| Stocki, D/ 2018/ Northern America Title- Knowledge translation and process improvement interventions increased pain assessment documentation in a large quaternary pediatric post anesthesia unit. | Retrospective observational study, with prospective observational follow up, using the Plan-Do Study-Act (PDSA) method. Benchmark audit n = 99 consecutive Post Anaesthetic Care Unit (PACU) charts audited in the first week of July 2013. Reaudit n = 20 randomly selected charts audited at 4, 5 and 6 months after the initial audit. | 1. PACU charts modified 2. Education 3. Audit and feedback | Proportion of charts that had at least 1 pain assessment documented. | Baseline audit - 68/99 (69%) had at least 1 pain score documented, an average of 4 pain assessments were documented per patient. Pain assessment documentation increased to > 90% at 4 and 5 months, respectively and to 100% by 6 months. |
| Stewart, S/2009/USA Title- “Measurement Monday": One facility's approach to standardizing skin impairment documentation. | Before and after study. A 2 year quality improvement initiative. A Baseline chart audit in 2005 (n = 54). Post intervention chart audits in 2006 (n = 27)and 2007 (n = 27) | 1. Measurement Monday - designate day to measure wounds 2. A documentation tool 3. Education | Percentage of charts without wound measurement documentation. | Charts without wound measurement documentation declined from the baseline audit (2005) = 32/54 (59.3%); 2006 audit = 10/27 (37%); 2007 audit = 4/27 (14.8%). After 2 years the proportion of charts containing complete wound measurement documentation improved from 41% to 85%. |
| Sandau, K/2015/USA Title- Computer-assisted interventions to improve QTc documentation in patients receiving QT-prolonging drugs | Before and after study. A multi-site study with baseline measurements (n = 1517), at 3 months post intervention (n = 1,301) and at 4-6 months post intervention (n = 1,193) | 1. Computerized enhancements in the EHR (prompts and automatic calculation of the QTc) 2. Mandatory education | Whether nurses documented Corrected QT Interval (QTc) measurements in patients EHRs during the hospital stay. Relationship between hospital size and QTc documentation | Results: Percentage of patients who had appropriate QTc documentation at baseline = 263/1,517 (17.3%); at 3 months = 757/1,301 (58.2%); at 4-6 months = 741/1,193 (62.1%). The effect of the intervention was sustained at 6 months after the intervention. Inpatients in larger hospitals were considerably more likely to have QTc documentation than patients at smaller hospitals i.e. 46.4% vs 27.2% |
| Rykkje, L/ 2009/ Norway Title- Implementing Electronic Patient Record and VIPS in medical hospital ward: evaluating change in quantity and quality of nursing documentation by using the audit instrument Cat-ch-Ing. | Before and after study. Pre-test with paper records (PR) in the fall of 2003 (n = 60); post-test in fall of 2004 with EHR and VIPS (n = 60). | 1. Education 2. Electronic record 3. VIPS | Differences in mean values between PRs and EHRs | Mean sum score for PR = 33/82; Mean sum score for EHR = 29.7/82 |
| O’Connor, T./ 2014/USA Title- Improving trauma documentation in the emergency department | Before and After study. An initial retrospective analysis of all trauma charts during a randomly selected month (n = 70). Ongoing chart audits over 8 months for every chart that fit the criteria (n = 1,066). | 1. Education 2. New trauma flow chart 3. Audit and personal feedback by peer review, this was incentivised by being included in the yearly performance evaluations. | The number of charting deficiencies per month to be 15 or fewer; overall quarterly documentation compliance | Deficiencies = no. deficiencies/total no. of charts audited - Sept = 53/156(34%), Oct = 41/122(33%), Nov = 15/124(12%), Dec = 13/130(10%), Jan = 20/122 (16%), Feb = 16/113(14%), March = 21/142(15%), Apr = 19/157(12%). Compliance with vital sign charting rose from 62% to 80%; Neurological charting compliance rose from 47% to 72%. |
| Okoyo Nyakiba, J/2014/ Kenya Title- Reporting and documentation of adverse drug reactions by health care professionals at a Kenyan public hospital: a best practice implementation project. | JBI PACES, in 3 phases - 1. Audit design and a retrospective baseline audit (n = 44), 2. Best practice implementation, 3. Post-implementation audit (n = 30). | 1. Education 2. Ensure availability of reporting forms 3. Provide feedback; 4. An in-house Adverse Drug Reactions (ADR) database was developed. | Percentage compliance with each criteria | Criteria 1. Improved from 7% to 63% compliance. 2. from 0% to 29%. 3. from 45% to 83%. 4. from 9% to 94%. 5. from 2% to 20%. 6. from 5% to 50%. 7 from 5% to 37%. 8. from 2% to 3%. 9. from 0% to 100%. |
| Nomura, A/2018/Brazil Title- Quality of electronic nursing records: the impact of educational interventions during a hospital accreditation process | Before and after, retrospective study. Pre-test 1 month before the accreditation process (n = 112); post-test 1 month after the accreditation process (n = 112). | 1 Education 2. Update the EHR nursing assessment tool 3. Creating an acronyms list 4. Review of standard operating procedures. | Median compliance score (Md) and Interquartile Range (IQR). Percentage change in compliance. | Pre-test Md = 9 (IQR, 7-10); Post-test Md = 19 (IQR, 17-20). Pre-test 67.9% of records were considered compliant, Post-test 83.9% were considered compliant. 9/12 items showed a significant improvement. |
| Mykkanen, M/2012/ Finland Title- Nursing audit as a method for developing nursing care and ensuring patient safety | Before and after study. Study 1 at the hospital level - audit in 2010 (n = 1274) and reaudit in 2011 (n = 1,366). Study 2 at the Coronary Care Unit (CCU) level - audit Spring 2010 (n = 20), intervention, re audit Autumn 2010 (n = 20) and Spring 2011 (n = 20). | Study 1 -intervention not stated Study 2 CCU - Education | A score out of 1 for each domain, for a total score out of 12. | Results: Study 1 (hospital wide) 2010 = 7.29/12; 2011 = 8.01/12, i.e. the overall level of documentation remained satisfactory. Study 2 (CCU) Spring 2010 = 7.85/12; Autumn 2010 = 11.10/12; Spring 2011 = 11.35/12 i.e. the level of document improved from satisfactory to excellent and was maintained. |
| Meyer, L/2019/USA Title- Cohorting trauma patients in a medical/surgical unit at a level 1 pediatric trauma center to enhance interdisciplinary collaboration and documentation | Before and after study. Data 2.5 years prior to and following the intervention were compared to determine the impact of the interventions on the compliance with FIM and CRAFFT screening documentation by nursing staff. Sample size not stated. | 1. Introduction of cohorting trauma patients to medical/surgical unit 2. Instituting a daily interdisciplinary trauma patient round 3. Education 4. Results from a pre intervention survey were used to improve the systems for documentation. | Percentage change in compliance with FIM and CRAFFT documentation. | 2015 Functional Independence Measure (FIM) = 72%, CRAFFT = 61%; 2016 FIM = 73%, CRAFFT = 64%; 2017 FIM = 94%, CRAFFT = 84%. |
| Margonari, H/2017/ USA Title- Quality improvement initiative on pain knowledge, assessment, and documentation skills of pediatric nurse. | Before and after study. A prospective pre and post intervention design with 3 assessment points - baseline prior to the education session (n = 153), immediately after the education session (n = 159) and follow up at one month after the education session (n = 99). | 1. A survey was conducted to identify specific knowledge deficits. 2. Education 3. Policies, procedures and a protocol were created. | Percentage improvements in pain documentation across 4 domains - 1. Pain assessment done. 2. Appropriate scales used. 3. intervention delivered. 4. Pain reassessment done. | 1. Pain assessment done- baseline = 66/153(43.1%), post = 103/159(64.8%), follow up = 67/99(67.7%). 2. Appropriate scale used- baseline = 20/153(13.1%), post = 123/159(77.4%), follow up = 81/99(81.8%). 3. Intervention delivered - baseline = 3/9(33.3%), post = 21/25(84%), follow up = 8/10(80%). 4. Pain reassessment done- baseline = 7/9(77.8%), post = 11/25(44.0%), follow up = 4/10(40%) |
| Karp, E/2019/USA Title- The changes in efficiency and quality of nursing electronic health record documentation after implementation of an admission patient history essential data set. | Before and after study, experimental pre and post nonrandomised prospective cohort design. Pre intervention data for patient admission histories was collected 30 days prior to the intervention (n = 904), post intervention data was collected over 30 days starting from 20 days post intervention (n = 805). | 1. A modified Delphi evaluation of the original Admission Patient History (APH) 2. Reduce the number of essential data elements from 215 to 58 in EHR. | The percentage of data elements captured and the number of clicks and time to complete an APH. | Results: A 6% increase in the data elements captured from pre-intervention (mean = 48%) to post-intervention (mean = 54%). The average time spent documenting decreased by 72% (6.76 min) The mean decrease in the number of clicks to document the APH was 115.6 (76%). |
| Jackson, S/2010/USA Title- The efficacy of an educational intervention on documentation of pain management for the elderly patient a hip fracture in the Emergency Department | Before and after study. A retroactive chart audit Jan through Aug 2006 (n = 151), intervention from Sept to Oct 2006, post intervention audit Jan through July 2017 (n = 151). | 1. Education | Rate of documentation compliance i.e. 1. Pain assessment within 2 min of admission. 2. First pain treatment < 60 min. 3. Pain reassessment < 60 min after pain treatment. | 1. There was 100% compliance for first pain assessment for pre and post the education intervention. 2. Time to first pain treatment < 60 min = no significant difference. 3. Pain reassessment |
| Hayter, K/2015/ USA Title- Improving pain documentation with peer chart review. | Before and after study. Retrospective quality audits of EHR records over a 9 month period. Sample size: not stated (but n = 426 taken from the graph) | 1. Education Tuesday- held weekly in Feb 2010 2. Retrospective audits with feedback, peer chart reviews with personal feedback. 3. Revision of the EHR flow sheet. 4. A quality improvement Registered Nurse Registered Nurse (RN) was assigned to each unit. | Percent of change for the median score of documentation of pain assessment and reassessment. | Results: staff completion rate for peer chart reviews was 85%. Baseline documentation was 17%; after the introduction of Tuesday education documentation decreased to 10%; when peer chart review was initiated the median score of pain documentation increased to 72%. Over 9 months the median score of pain documentation increased from 27% to 72%. |
| Hubner, U/2015/ Germany Title- Evaluating a Proof of Concept approach of the German Health telematics Infrastructure in the context of discharge management. | Randomized trial study. Discharge patients were randomly allocated to the eDischarge group or the paper discharge group. Sample size: eDischarge n = 9, paper discharge n = 3. | 1. An eDischarge application. 2. Education. 3. Two user supporters provided | Completeness measured by sum of entries and a Likert scale. | Results: eDischarges were rated better than paper discharges for completeness i.e. paper = poor to satisfying; eDischarge = sufficient to good. The average number of eDischarge entries was greater than paper discharge entries in 6/8 categories, less in 1/8 and the same in 1/8 categories. eDisharge sum of entries = 18.4, paper sum of entries = 10.7. |
| Kamath, B/2011/USA Title- Using improvement science to increase accuracy and reliability of gestational age documentation | Plan, Do, Study, Act. A prospective cohort study. A baseline audit of EHRs was conducted in Sept 2009 followed by phase I (Fall of 2009) interventions through to phase IV (May 2010) interventions. Sample size: n = 8,795 deliveries. | 1. Education 2. Nurses documenting why EHR cannot be filled 3. Ward clerk checks for completion 4. New form 5. Drs contacted if form incomplete or incorrect 6. Real time audit and personal feedback 7. Stickers for charts with incomplete EHR 8. pregnancy card for pregnant women containing GA information | Percentage of EHR with complete Gestational Age (GA) dating. | Results: Baseline audit = 69/292 (24.6%), Oct/Nov 2010 audit = 294/361(81.4%). |
| Jacobson, T/2016/USA Title- Enhancing documentation of pressure ulcer prevention interventions: a quality improvement strategy to reduce pressure ulcers. | Before and after study. DMAIC approach - Defining the problem, Measuring performance, Analyzing the process, improving processes, controlling the process improvements. Sample size: not stated. | 1. Computer generated monthly reports 2. EHR modifications e.g. triggers, standardized language and location 3. Education 4. Guidelines 5. Personal feedback |
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship and/or publication of this article.
