NURSING DOCUMENTATION

“It 's as Easy as ABC”

Fiona RussellSNAP CoordinatorWar Memorial Hospital, Waverley

BACKGROUND TO QUALITY PROJECT

Problems with Nursing Documentation: • Not always clear, easy to follow and relevant• Information was hard to access by other team

members • There was a lack of critical thinking and problem

solving and little evidence of care planning at times.

BACKGROUND & DEVELOPMENT• 2012 Informal Introduction by the Clinical Care

Coordinator (CCC)

• 2013 The ABC project was redesigned with a structured format via a Working Party with buy in from management & staff

• 2014-2015 –Formal education intervention included review through audits, and surveys; development of guidelines, promotional material, etc

By ensuring documentation reflects:

• Key areas in rehabilitation nursing

• The patient’s progress/deterioration

• Application of critical thinking, problem solving, goal setting and treatment planning.

• Documentation that is accessible & useful to all members of the multidisciplinary team

Goal : To improve nursing documentation

DOCUMENTATION PROJECT

• Introduction of a suitable framework• Education of nurses and other staff • Marketing and promotion • Assessing the impact of the framework in terms of

quantity and quality of documentation

WHAT IS NURSING ABC DOCUMENTATION?It is a method of recording in the patient’s notes using the mnemonic of part of the alphabet “ABCDEFGHI” to prompt nurses to record aspects of patient’s rehabilitation care. ABC was created by Andrew Murray, CNC at POWH Aged Care Rehabilitation Ward.ABCDEFGHI represents:

A= Ability & Assistance in ADLS

B=Behaviour &Communication

C=Continence Management

D= Dressings or Pressure Care

WHAT IS NURSING ABC DOCUMENTATION?

E= Eating & Drinking

F= Falls Risk/Mobility

G=Goals

H= Home & Health Promotion discharge plan

I=Investigations, Impairments, Illness;

WHAT WE DID• Support for project-Management & nursing support• Baseline audit –retrospective• Education Intervention:

-Participatory approach involving small nursing focus groups -inservices

• Marketing-posters, flyers, emails, etc• Documentation Guidelines• Satisfaction Surveys-Nursing staff, student nurses,

allied health staff

NURSING AUDIT RESULTS: Baseline Audit November 2011: pre ABC Educationn=20

16

8

10

5

10

10

0

1

0 5 10 15 20

A=Ability & Assistance in ADLs

B=Behaviour & Communication

C=Continence Management

D=Dressings or Pressure Care

E=Eating & Drinking

F=Functional Mobility Falls Risk

G=Goals/ H=Home

I - Investigations

NURSING AUDIT RESULTS Baseline Audit November 2011 & post informal ABC Education April 2012n=20

16

8

10

5

10

10

0

1

17

14

16

6

15

11

5

9

0 5 10 15 20

A=Ability & Assistance in ADLs

B=Behaviour & Communication

C=Continence Management

D=Dressings or Pressure Care

E=Eating & Drinking

F=Functional Mobility Falls Risk

G=Goals/ H=Home

I - Investigations

16

8

10

5

10

10

0

1

17

14

16

6

15

11

5

9

20

20

20

19

20

20

9

19

0 5 10 15 20

A=Ability & Assistance in ADLs

B=Behaviour & Communication

C=Continence Management

D=Dressings or Pressure Care

E=Eating & Drinking

F=Functional Mobility Falls Risk

G=Goals/ H=Home

I - Investigations

3rd Audit, December 2014: post formal ABC education2nd Audit, April 2012: post ABC informal educationBaseline Audit, November 2011: pre ABC education

NURSING AUDIT RESULTS FOR ALL AUDITSn=20 for each audit

% OF IMPROVEMENT

2060

5070

5050

4590

A=Ability & Assistance in ADLs

B=Behaviour & Communication

C=Continence Management

D=Dressings or Pressure Care

E=Eating & Drinking

F=Functional Mobility Falls Risk

G=Goals/ H=Home

I - Investigations

Total % of improvement from first to third audit

NURSING AUDIT RESULTSFormal Education Framework =effectiveComparison of the proportion of files (n=20) Complying vs non compliance was performed using the chi square statistic. Each individual 8 domains (A,B,C,D,E,F,G/H,I) showed significant improvement from baseline audit when compared to the final audit (p

ALLIED HEALTH FEEDBACK: WHAT IS GOOD ABOUT THE NURSING ABC FORM OF DOCUMENTATION?

“I enjoy that it is well structured and I can track the relevant sections to the information I am seeking. It assists thenursing entries to be succinct and holistic”.

Comment from one Allied Health respondent

• EasierFormat• Easy to read•Easy to Follow•Easy to locate information•Clear and concise•Relevant

HOW COULD THE NURSING ABCDE SYSTEM OF DOCUMENTATION BE IMPROVED TO HELP YOU IN YOUR ROLE?

• AH Staff made more aware of it e.g orientation

• Consistency in reporting levels of Independence

• Understanding the levels of assistance

“Ensuring that all people understand the various levels of assistance egmin, mod, max assist”.Comment from one Allied Health respondent

• Easy to use• Easy format• Easy to read • Easy to follow • Easy to locate information • Easy to assess patient needs

THE OVERALL VIEW FROM 3 X SATISFACTION SURVEYS:

“It’s as easy as ABC”

WHERE DO I FIND INFORMATION ON ABC?• At the front of the

patient’s medical records file (inside cover)

• The ABC ‘SMART’ card

MARKETING

ADDITIONAL DEVELOPMENTS: IMPROVING HANDOVER

Nursing Care Plan

Daily Handover

Tool

ADDITIONAL DEVELOPMENTS: ASSISTS WITH FIM SCORING COMPLETION

Improved ability to FIM score items:e.g• Continence• Transfers• Toileting• Cognition items

RECOMMENDATIONS

• Provide feedback • Provide education to allied health staff on ABC Nursing

Documentation • Seek input from Allied Health Staff-info they require

e.g Pain/Continence/ Slept well• Education to all staff on reporting levels of dependence

e.g clearer details regarding minimum, moderate and maximum assistance.

THE NEXT STEP FORWARD: WHERE TO FROM HERE?

Qualitative auditTo determine the quality of documentation within each domain of ABC.

Ensure Sustainability To embed this framework into the performance and development of rehab nurses. This will require commitment to include this package within orientation and continuous practice development.

THE NEXT STEP FORWARD

Research

CONCLUSIONThis project has demonstrated a significant improvement in documentation of the essential elements of rehabilitation by nurses in a geriatric rehabilitation facility following a structured education program.

Questions?

Nursing DocumentationBackground to quality projectBackground & DEVELOPMENTSlide Number 4DOCUMENTATION PROJECTWHAT IS Nursing ABC DOCUMENTATION?WHAT IS Nursing ABC DOCUMENTATION?WHAT WE DIDAUDIT RESULTSAUDIT RESULTSAUDIT RESULTS% OF IMPROVEMENT�Nursing AUDIT RESULTS�ALLIED Health feedback: What is good about the Nursing ABC form of documentation?How could the Nursing ABCDE system of documentation be improved to help you in your role?Slide Number 16Where do I find information on ABC?MarketingSlide Number 19Slide Number 20Recommendations�The next step forward: WHERE TO FROM HERE?The next step forwardCONCLUSIONSlide Number 25Slide Number 26