Nursing Documentation

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Team ID: 
College / Administrative Unit: 
Student Affairs
Date Started: 
October 2010
To gather relevant patient information to ensure accurate patient care advising for health and liability issues/reasons when suggesting over the counter medication.

When advising female patients to take over the counter medication, it is essential to document the last menstrual period, to evaluate the possibility of pregnancy, for overall patient health and liability issues. The goal of this QI activity is to eliminate undocumented “last menstrual period” when offering nurse phone advice in regards to suggesting over the counter medication. Our goal is 100% compliancy because of the importance of advising accurate patient care.

Data is obtained by chart reviews. Phone advice related encounters were reviewed, evaluating the presence of documented “last menstrual period”, when an over the counter medication was suggested according to symptoms presented.
Starting compliance was measured at 98.4 %.
The corrective actions included - changing the electronic health record phone template to include the LMP documentation entry box placement in the electronic chart, exactly above the list of medications recommended to the patient for self care, in the expectation of reminding the advice nurse to include the last menstrual period in the documentation.
Also implemented were verbal reminders given to the phone advice nurses during clinical meetings and written reminders given via messaging through electronic health record by the nursing supervisor.
Remeasurement in Jan 2011 reveals an increase in compliance to 99.6%.
No additional corrective actions are planned. Ongoing quality assurance will include verbal reminders during clinical nursing staff meetings and written reminders generated via messaging to phone advice nursing staff.
The Nurse Manager will spot check records each month as a measure of continued compliance.

Contact Person: 
Nancy Lambert
  • Mary Pat Griffin, Leader
  • Agatha Glusko, Member
  • Kathy Petroff, Member