The Science Journal of the American Association for Respiratory Care

2012 OPEN FORUM Abstracts

EDUCATIONAL INVENTIONS TO IMPROVE CLINICIAN DOCUMENTATION.

Kenneth Miller, Linda Cornman, Kristen Lai, Kelly Torres, Maggie Berzak; Lehigh Valley Health Network, Bath, PA

Intoduction: Timely and accurate documentation is extremely important to enhance shift communications and review sequencing of clinical events. Accurate documentation is the cornerstone of being able to evaluate the patientÂ’s progress and assess the patientÂ’s response to clinical interventions. Another importance of proper and timely documentation is the legal ramification. To meet the above objectives, our department require that two SBAR (Situation, Background, Assessment, Recommendation) notes. One note is to be documented at the start of each shift and one at the end of the shift. Documentation can occur between notes if warranted. Methods: To examine our practice of documentation, we collected fifty random pre/post assessment notes. We reviewed the notes to assess if they contained the elements of SBAR as required. Post assessment, we provided SBAR format reviewed during our mandatory educational days, the completion of an on-line learning module, and attendance at a documentation presentation provided by our Legal/Risk Management Team. Results: Post education the improvement in SBAR documentation increased from seventy to ninety percent. Individualized and content focus education was conducted and currently our documentation scores are being maintained above ninety percent on a monthly basis. (Table 1) Conclusion: The importance of content education and vigilant monitoring insures precise and appropriate staff documentation. Precise documentation helps to provide clear clinical goals and helps optimize patient outcomes. Sponsored Research - None SBAR Note Results