Abstract WP369: Knowing the Score: Documentation of Bleeding Scores for Hemorrhagic Stroke Patients
| Autor: | Sonia Guerra, Denise Levesque, Betty Robertson, Nicole Wolber, Nancy Nunez, Nili Steiner, Laurie Paletz |
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| Rok vydání: | 2018 |
| Předmět: |
Advanced and Specialized Nursing
medicine.medical_specialty Retrospective review Quality management Stroke patient business.industry Certification Hemorrhagic strokes medicine.disease Documentation medicine Physical therapy Neurology (clinical) Cardiology and Cardiovascular Medicine business Stroke Neuro icu |
| Zdroj: | Stroke. 49 |
| ISSN: | 1524-4628 0039-2499 |
| Popis: | Background: Intracranial hemorrhage (ICH) scores and Hunt and Hess/Fisher scores (HHF) are important components in the documentation of hemorrhagic strokes. The accurate and timely documentation of these scores is a mandatory data point measure for Joint Commission (JC) certified Comprehensive Stroke Centers. The purpose of this project is to discuss the measures we implemented to improve documentation of the ICH and HHF scores and to highlight the remarkable improvement of documentation of the scores with our efforts. Purpose: The purpose of this project was to discover if a specific, user-friendly template and targeted education would increase documentation compliance. Methods: We did a retrospective review of percentage of compliance in documentation of ICH and HHF scores before the measure was mandated by the JC. We implemented the ICH and HHF score template into the Neuro ICU template and educated practitioners on the JC measure requirement and awareness of the template. We also educated our Code Brain team to document the scores upon initial assessment. We track and trended documentation with monthly review of percentage of compliance. We continue to provide feedback to practitioners when score documentation is not present in medical record and continue to monitor percentage of compliance. Results: The percentage of compliance at the beginning of the data capture for this measurement (Jan 2015) was approximately 6% for the first two quarters of 2015. After the implementation of the score template, the percentage of compliance was 50% for the last two quarters of 2015. We continued to meet with the Neuro ICU for targeted education of the measure requirement and provided feedback in cases of missing documentation. With the continued feedback and education, the percentage of compliance increased to approximately 92% in 2016, a huge improvement from 2015. Conclusions: Providing an user friendly template for practitioners along with education and feedback helped dramatically increase the compliance of documentation for an mandatory JC measure. |
| Databáze: | OpenAIRE |
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