Butt Fahad, Varghese Nisha, Elhadidi Ahmed, Abdulrahman Sarah, Ben Ayad Aimen
Neonatology, Tawam Hospital, Al Ain, ARE.
Pediatrics, Tawam Hospital, Al Ain, ARE.
Cureus. 2024 Dec 8;16(12):e75309. doi: 10.7759/cureus.75309. eCollection 2024 Dec.
Introduction This quality improvement (QI) initiative aimed to improve the clinical documentation of daily progress notes in the neonatal intensive care unit (NICU) by applying a standardized documentation template and conducting regular cycles of audit and feedback to ensure compliance and improvement. Methods Firstly, to better assess documentation practices impacting patient care, members of the NICU auditing team identified seven key points in medical records. These points were then used for the audit of 30 randomly selected "progress notes" for infants admitted to the NICU between January and June 2022. We introduced a new standardized progress note template in the NICU based on the initial seven key points considered essential in NICU documentation. Subsequently, we educated the staff on the latest changes and their impact on patient care delivery. Also, we raised awareness among the NICU staff regarding the quality improvement project we were running and the requirement to adopt the new standard template. We also ensured that everyone had access to the new template. The QI team analyzed NICU progress notes every three months from October 2022 to July 2023; 45 notes were reviewed per cycle, a total of 135 notes. With each cycle, we took feedback from NICU team members regarding the deficiencies and opportunities for improvement in clinical documentation and encouraged adherence to key points. A template for the specific needs of the NICU was redesigned based on feedback received from all stakeholders on how to reduce the obstacles in adopting and retaining compliance with the new template. Results Compliance with the "key elements" of documentation improved dramatically after introducing a new template and feedback system. In the final cycle, the overall compliance was 81% (p<0.0001), well above our initial target of 60% compliance. Conclusion A unit that implements targeted audit-and-feedback measures relevant to the clinical team requirement can substantially and consistently improve documentation.
引言 这项质量改进（QI）举措旨在通过应用标准化的文档模板并定期进行审核和反馈循环，以确保合规性和改进，从而提高新生儿重症监护病房（NICU）每日病程记录的临床文档质量。方法 首先，为了更好地评估影响患者护理的文档记录实践，NICU审核团队成员在病历中确定了七个关键点。然后，这些关键点被用于对2022年1月至6月期间入住NICU的婴儿随机抽取的30份“病程记录”进行审核。基于在NICU文档记录中被认为至关重要的最初七个关键点，我们在NICU引入了一个新的标准化病程记录模板。随后，我们对工作人员进行了最新变化及其对患者护理交付影响的培训。此外，我们提高了NICU工作人员对我们正在开展的质量改进项目以及采用新的标准模板要求的认识。我们还确保每个人都能获取新模板。QI团队在2022年10月至2023年7月期间每三个月分析一次NICU病程记录；每个周期审核45份记录，总共审核135份记录。在每个周期中，我们从NICU团队成员那里获取关于临床文档记录中不足之处和改进机会的反馈，并鼓励遵守关键点。根据从所有利益相关者那里收到的关于如何减少采用和保持对新模板合规性方面障碍的反馈，重新设计了一个符合NICU特定需求的模板。结果 引入新模板和反馈系统后，文档记录“关键要素”的合规性大幅提高。在最后一个周期中，总体合规率为81%（p<0.0001），远高于我们最初设定的60%的合规目标。结论 一个实施与临床团队要求相关的有针对性的审核和反馈措施的科室，可以显著且持续地改进文档记录。
