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Keywords

Charting compliance, Documentation quality, Nurse-to-nurse shift handoffs, Point-of-care technology, Shift report

 

Authors

  1. WU, MEI-WEN MS, RN
  2. LEE, TING-TING PhD, RN
  3. TSAI, TZU-CHUAN BS, RN
  4. LIN, KUAN-CHIA PhD
  5. HUANG, CHI-YI PhD
  6. MILLS, MARY ETTA ScD, RN

Abstract

Nursing shift report is vital for patient care. Accordingly, healthcare facilities have made great efforts to establish a standardized nurse-to-nurse shift handoff process to ensure patient care quality. The purpose of this study was to determine whether the use of a standardized mobile intershift handoff system would affect the quality of nursing documentation. The study is based on nursing handoff records from 19 inpatient units in four major care areas (internal medicine, general surgery, obstetrics/pediatrics, and long-term care) of a medical center in central Taiwan. Data collection was performed before and after implementation of the mobile, point-of-care handoff system in 2010. A medical review tool was used to compare 25-item charting compliance on 228 charts. Results show that the designed content of the handoff system was related to a corresponding compliance change in initial assessment, pain reassessment, and use of accurate abbreviation. Although overall compliance rates among inpatient units varied, the statistical test showed that the pattern of changes was consistent. As more items were added to the new handoff system for reminder purposes, documentation compliance increased; however, since the new handoff system did not include nursing diagnosis, patient outcome tracking compliance was reduced. The results of the study reveal that implementing a standardized point-of-care handoff system could improve nursing documentation compliance and quality.