Feedback tool improves staff documentation

Serves as an effective reminder

To provide feedback on documentation compliance, nurses in Orthopedic Services at Sacred Heart Medical Center in Spokane, WA, are given a sheet that shows them the areas in which they need improvement each time charts are audited. The feedback sheet follows the chart audit and has preprinted information and reminders, says Kris Becker, RN, MHA, director of Orthopedic Services. Areas covered include completion of the advance directive sheet, patient history, adult interdisciplinary data record, and plan of care with concerns, interventions, and expected outcomes listed.

When patient education assessments are not completed, that point is checked on the feedback sheet. The feedback tool reminds nurses that assessment covers a patient’s learning needs, preferences, and barriers to learning, and that all three sections need to be assessed.

"If their documentation did not include response to the pain management intervention, the feedback tool gives them a hint on ways to do that," says Becker. Incomplete documentation of pain management covers several issues that can be checked during a chart audit, such as:

  • There should at least be documentation of the patient’s pain rating at the beginning of your shift — initial assessment.
  • Please chart every time you ask the patient to rate their pain throughout the shift, even if it does not result in an intervention.
  • It is important to chart the patient’s response to the pain medicine. Even if you don’t ask the patient to rate their pain again until it is time for more pain meds, you can ask them, "Did the pain pills help your pain? What rating would you give that?" Then chart that in the response area.