Brezak, Magdaline

Cornman, Linda, BS, RRT-NPS

Lal, Kristen, RRT

Miller, Kenneth, MEd, RRT-NPS

Strohecker, Joel, BS, RRT

Torres, Kelly M, RRT

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksPatient Care Services / NursingEducational Interventions to Improve ClinicianDocumentationJoel Strohecker BS, RRTLehigh Valley Health Network, Joel.Strohecker@lvhn.orgKenneth Miller MEd, RRT-NPSLehigh Valley Health Network, Kenneth.Miller@lvhn.orgLinda Cornman BS, RRT-NPSLehigh Valley Health Network, Linda.Cornman@lvhn.orgKristen Lal RRTLehigh Valley Health Network, Kristen.Lal@lvhn.orgKelly M. Torres RRTLehigh Valley Health Network, Kelly_M.Torres@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/patient-care-services-nursingPart of the Medical Education Commons, Medical Sciences Commons, and the NursingCommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtStrohecker, J., Miller, K., Cornman, L., Lal, K., Torres, K., & Brezak, M. (2012). Educational interventions to improve cliniciandocumentation.AuthorsJoel Strohecker BS, RRT; Kenneth Miller MEd, RRT-NPS; Linda Cornman BS, RRT-NPS; Kristen Lal RRT;Kelly M. Torres RRT; and Magdaline BrezakThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/patient-care-services-nursing/373Respiratory Care Department, Lehigh Valley Health Network, Allentown, PAEducational Interventions to Improve Clinician DocumentationBackgroundJoel Strohecker BS, RRT, Kenneth Miller MEd, RRT-NPS, Linda Cornman, RRT-NPS, Kristen Lal, Kelly Torres RRT, Madeline Brezak, RRT		Timely and accurate documentation is essential:	 	 •	 enhances shift communications	 	 •		assists in evaluating the patient’s clinical progress	 	 •		evaluates the patient response to clinical interventions		Accurate and timely documentation can have legal ramifications.Study Design		We collected fifty random pre and post shift assessment notes.		We reviewed these notes to examine if they contained the elements of SBAR per our departmental policy.Departmental Policy		A clinical note is required at the start and end of each clinician’s shift.		The clinical note is to utilize the SBAR format:	 	 •	 S = Situation	 	 •		B = Background	 	 •		A = Assessment	 	 •		R = Recommendation		Documentation can occur between notes if warranted.		Based on the review we required:	 	 •	 a SBAR format review session at our annual educational days.	 	 •		staff to complete an on-line learning module focusing on the correct SBAR formatting.	 	 •		A documentation presentation was provided by our institution’s legal/risk management team.		Post education there was an improvement in SBAR documentation from 70% to 90%.		Monthly QA was performed to insure that SBAR notes continued to be written per policy.Conclusions		Content education and vigilant monitoring insure precise and appropriate staff documentation. 		Precise documentation helps to provide clear clinical goals and optimizes patient outcomes.05101520253035404550Pre-Ed PostEd# ofCorrect Notesper CategorySituation Background Assessment Recommendation90% CorrectOverall PostEd70% CorrectOverall Pre-EdResultsPre-Post Assessment Outcomes

Educational Interventions to Improve Clinician Documentation

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1383&context=patient-care-services-nursing

Educational Interventions to Improve Clinician Documentation

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Lehigh Valley Health Network: LVHN Scholarly Works