Toward more accurate documentation in neurosurgical care

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a “system-based” progress note template was changed to a “problem-based” progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

The Role of Head Nurse, Critical Thinking Nurse And Documentation of Integrated Patient Progress Note: Cross Sectional

The study aimed to identify the relationship between the role of head nurse and critical thinking of nurse to the documentation of integrated patient progress note. The study used a descriptive correlation design, a cross sectional approach, with a sample of 69 nurses who documented integrated patient pogress note, using cluster sampling techniques, through Pearson, Spearman, Mann Whitney and Linear Regression analyzes. There was a significant relationship between the role of head nurse (p=0.038; α=0.05) and the nurse's critical thinking (p=0.003; α=0.05) to the documentation of integrated patient progress note. Critical thinking of nurses is the most influential factor in documenting integrated patient progress note. Here needs to be a policy, evaluation and monitoring of the nursing manager through self-development in the application the role of head nurse, critical thinking of nurse and the implementation of documentation of integrated patient progress note