Implementing mandatory early warning scoring impacts nurses' practice of documenting free text notes.

AIMS AND OBJECTIVES

To evaluate whether implementing the Modified Early Warning Scoring system impacts nurses' free text notes related to Airway, Breathing, Circulation and Pain in general ward medical and surgical patients.

BACKGROUND

The quality of nursing documentation in patient health records is important to secure patient safety, but faces multiple challenges whether being paper-based or electronic. Nurses' ability to draw a complete picture of the patient situation is thereby compromised. Structured use of the Modified Early Warning Score, found to reduce unexpected death, might affect nurses' free text documentation of clinical observations.

DESIGN

A prospective, pre- and postinterventional, nonrandomised study adhering to the EQUATOR guideline TREND.

METHODS

Data on nurses' free text notes were obtained in 1,497 patient records during one preinterventional (March-June 2009) and two postinterventional study periods (September-December 2010 and March-June 2011) in a Danish university hospital. Data were organised by the Airway, Breathing and Circulation principles and by nurses' working shifts in the 56 hr surrounding the first recording of deviating vital parameters or a Modified Early Warning Score ≥ 2. Preinterventional free text notes were compared with notes from the two postinterventional periods, respectively.

RESULTS

In the 8-hr working shift where deviations in vital parameters were recorded for the first time, nurses' free text notes related to patients' breathing (B) increased significantly, comparing 2009 with 2010 and 2011, respectively. In the 24 hr following initial deviations in vital parameters, a significant increase in free text notes was identified concerning Airway, Breathing and Circulation-related symptoms or problems.

CONCLUSION

Mandatory use of the Modified Early Warning Score and related implementation activities significantly impacts nursing documentation of free text notes.

RELEVANCE TO CLINICAL PRACTICE

Nurses' practice of communicating observed clinical symptoms by documenting free text notes should be supported through measures to enhance situation awareness.