Quality improvement in clinical documentation: does clinical governance work?

Abstract

IntroductionThe quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation.MethodsA quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist.ResultsThere were no differences between a nurse’s demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program.ConclusionAlthough some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.

Information seeking and retrieval skills of nurses: Nurses readiness for evidence based practice in hospitals of a medical university in Iran

“…The implementation of healthcare policies is centralized in Iran [22] and the ministry of health governs all hospitals. Therefore, the distribution of healthcare providers is similar in all hospitals around the country.…”

Nursing documentation in palliative care: An integrative review

“…Such educational programmes should provide nurses with the competence to document adequately but also encouraged nurses to view their documentation as a crucial aspect of care and recognise its value to other disciplines outside the profession [35]. However, while Jefferies et al [32] pre and post programme documentation audit, illustrated vast improvements in nursing documentation, Dehghan et al [57] found that nursing documentation did not improve after doi: 10.7243/2056-9157-5-3 a two year clinical governance programme, which included education. In addition, it is recognised that regular auditing of clinical records can improve standards of record keeping and hence patient care [42].…”

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

“…This may also have encouraged staff to document nursing interventions. Other studies have found documentation of nursing interventions to be lacking (Hale et al 1997;Instefjord et al 2014;K€ arkk€ ainen et al 2005), and improvements in clinical documentation are often difficult to achieve in practice (Dehghan et al 2013). The documentation of interventions is important, as it allows other clinicians to subsequently determine what care has been provided, alongside patient progress (Kelley et al 2011), and improvement in documentation has been linked to improvements in patient care (Prideaux 2011;Sequist 2015).…”