Proper documentation of a patient’s response to administered medications reflects the care provided to the patient. Accurate medical records provide an important means of communication between clinicians, a basis for evaluating treatment and response to those treatments and protecting the legal interests of the patient, facility, clinicians and nursing staff.
The goal of this QI study is 90% complete documentation of the resting patient’s response to ordered medications.
The data was collected thru a chart review of encounters where medications were administered to resting patients. The charts were reviewed for the type of medication given, the length of time the resting patient was observed while in the clinic and if the patient’s response to the medication was documented.
The corrective actions include electronic health record template changes. The addition of pain scales and patient response options for nausea and fever relief will act as reminders for nursing staff when charting. Another corrective action will include informing and educating nursing staff about the importance of proper documentation with regards to a patient’s response to a medication. Verbal as well as written reminders will be presented at clinical meetings and educational in-services.
A re-measurement of the data will occur in May of 2011 after the corrective actions have been implemented to determine their effectiveness.
- Agatha Glusko, Leader
- Mary Pat Griffin, Member
- Kathy Petroff, Member