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Keywords

Documentation, Peer advisement, Performance improvement

 

Authors

  1. Wainwright, Gail A. BSN, RN
  2. Stehly, Christy D. BS
  3. Wittmann-Price, Ruth A. DNSc, RN, CNE

ABSTRACT

Nursing documentation for trauma resuscitation has improved significantly at our level I trauma center because of the introduction of our Emergency Nurse Documentation Improvement Tool (END-IT). The END-IT system was implemented as a performance improvement model and utilizes existing computer software. It provides quick computerized feedback to professional nurses when documentation of trauma cases needs further attention. The feedback is provided in written form and uses peer mentoring to improve accountability in documentation. The program has been successful and has decreased documentation omissions and mistakes by 21%.