Date of Graduation

Summer 8-9-2024

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Dr. Susan Mortell

Second Advisor

Dr. Cynthia Huff

Abstract

Problem: Multiple documentation “fallouts” on a medical-surgical unit at Hospital X led to investigations and mandatory action plans requested by the California Department of Public Health (CDPH). The focus was on missing documentation from nursing assessments (skin, pain, reassessments, and nursing care plans). Current compliance rates on the unit were around 50%. It was noted that orientation and training deficits contributed to the poor documentation findings.

Context: Hospital X expanded licensed medical surgical and telemetry (MST) beds from 93 to 167 in less than four years. The use of travel nurses and the expansion of the nurse residency program overburdened orientation processes and contributed to the problem.

Interventions: An emphasis on documentation training during orientation included preceptor checklists, the development of clear documentation requirements, and routine chart audits for compliance.

Measures: The primary outcome measure is to improve the effectiveness of orientation training on documentation compliance to satisfy the CDHP required action plan.

Results: Improvement in pain reassessment and patient safety intervention documentation because of improved orientation and training improved by 80% within the first month after training.

Conclusions: Results from the intervention demonstrate steady progress toward the goal of at least 90% compliance with documentation requirements over the last three months. Further interventions to sustain improvement and meet CDHP requirements are an ongoing effort.

Keywords: orientation, training, inconsistencies, nursing documentation, quality improvement

Download

To download restricted works from off campus you must have a USF email address and use it to create an account for the repository.

  Contact Author

Share

COinS