Charting the Course: Improving Psychotropic Medication Documentation Through Staff Education to Promote Patient Safety and CMS Compliance

Author

Anne J. Bertram RNFollow

Date of Graduation

Winter 12-12-2025

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Dr. Tania Borja-Rodriguez PhD, RN, FNP-BC

Abstract

The University of San Francisco master’s level nursing program culminates with a clinical nurse leader (CNL) quality improvement project. The objective of this project is to reinforce the program’s didactic CNL classes by allowing students the opportunity to design, implement, and analyze a quality improvement project in a microsystem. SETTING: Skilled nursing facilities often prescribe psychotropic medications to help manage residents’ behavioral and psychological symptoms. Due to the possibility of side effects and increased sedation, there are concerns for patient safety and quality of life. Inadequate management of these patients and symptoms compromises patient safety and breaches state and federal regulations. OBJECTIVE: The site for the QI project had 0% documentation compliance and

data collected revealed low levels of nurse understanding and knowledge regarding

documentation requirements and regulatory compliance. AIM: To evaluate the effectiveness of a teaching intervention to enhance nurse knowledge and confidence to meet regulatory and quality compliance. METHODS: Nursing staff received education and resources to increase their knowledge, comfort, and adherence to documentation standards. In addition, emphasis was put on the importance of documentation and observation for patient safety. Pre- and post-intervention survey data measured nurses’ understanding and comfort with documentation requirements. RESULTS: Average nurse confidence with psychotropic medication documentation increased from 44.4% to 60.7% post intervention. Knowledge of documentation processes improved from 80% to 85.7%. However, staff knowledge of CMS criteria for unnecessary use of psychotropic medication decreased from 77.8% to 42.8%. CONCLUSION: This project highlighted the effectiveness of educational interventions to increase nursing understanding and comfort with documentation standards. Although there were improvements in nurses’ self-reported knowledge, continued education on staff knowledge of CMS requirements is needed. In addition, follow up is required to understand the long term effects of this increased comfort and understanding on actual documentation practices. The team suggests ongoing staff education and follow up analysis of documentation compliance

Recommended Citation

Bertram, Anne J. RN, "Charting the Course: Improving Psychotropic Medication Documentation Through Staff Education to Promote Patient Safety and CMS Compliance" (2025). Master's Projects and Capstones. 1962.
https://repository.usfca.edu/capstone/1962