Quality of nursing documentation before and after the Hospital Accreditation in a university hospital.
Aline Tsuma Gaedke Nomura, Marcos Barragan da Silva, Miriam de Abreu Almeida
PMID 27878216WHAT IT FOUND
Nursing documentation quality improved after a bundle of accreditation-preparation activities: the typical total score rose from 31 to 43 out of 58.
The bundle had many parts, so no single activity can be credited.
Key findings
01The total nursing documentation score, out of 58 points, rose from a median of 31 in 2009 to a median of 43 in 2013.
02All four Q-DIO domains showed significant differences between the years, and 24 of 29 items improved significantly.
03The intervention was a package of nurse-led activities during accreditation preparation, including clinical case studies, printed bulletins and electronic newsletters, regular support group meetings, theoretical and practical training, brochures and manuals, restructuring of computerized documentation, anamnesis and nursing physical examination changes, patient and relative education information, obligatory assessment items, training space, disclosure and doubt clarification, institutional abbreviations list, focused groups, active and educational visits, educational evaluations, strategies to remedy or alleviate problems, training lectures, standard operating procedures, and distance learning courses.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study compared records from two periods, so it cannot separate the effect of time or other changes. The intervention was a bundle of many nurse-led activities, so the study cannot show which activity improved documentation. The sample was only adult clinical and surgical inpatient records from a public university hospital, and the authors state the results are limited to that scenario. The outcome measured was documentation completeness, not patient health outcomes or safety events.
Declared interests
The paper reports funding by Fundo de Incentivo à Pesquisa e Eventos (FIPE), process #130389. It was extracted from a master's thesis. The supplied text gives no author conflict-of-interest statement.
The easy way to misread this
Do not read the score improvement as proof that accreditation alone caused better documentation or that patients had better outcomes. The study measured nursing records, not patient outcomes, and the intervention was a bundle of many nurse-led activities.