Improving Documentation of Symptom Management in General In-Patient Hospice

Abstract

The purpose of this quality improvement (QI) project was to evaluate nursing compliance of using an evidence-based flowsheet for General In-Patient (GIP) symptom management with a secondary purpose of improving nursing documentation of GIP care needs. An evidence-based flowsheet and nurse pocket guides were developed and presented with an educational PowerPoint presentation to Registered Nurses at an inpatient hospice facility. Patient’s charts were reviewed pre and post implementation of the intervention. There were six areas of the nursing documentation that were audited. These six areas were: documentation of GIP reason, appropriateness of GIP reason, thorough documentation of the GIP symptom, documentation of the symptom intervention, documentation of the outcome to the intervention, and documentation of the interdisciplinary team visit or need for a visit. Only nurse notes were audited. Post intervention documentation was improved in all six areas by over 30%. Although the initial improvement in nursing documentation was found, as time elapsed, some of the nurses began to revert to their old documentation habits. Recommendations for future QI in improving GIP documentation include policy changes, continuing education, regular chart audits, and recognition for good documentation.