Can written nursing practice standards improve documentation of initial assessment of ED patients?

Considine, Julie, Potter, Robyn and Jenkins, Jane 2006, Can written nursing practice standards improve documentation of initial assessment of ED patients?, Australasian emergency nursing journal, vol. 9, no. 1, pp. 11-18, doi: 10.1016/j.aenj.2006.03.004.

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Title Can written nursing practice standards improve documentation of initial assessment of ED patients?
Author(s) Considine, JulieORCID iD for Considine, Julie
Potter, Robyn
Jenkins, Jane
Journal name Australasian emergency nursing journal
Volume number 9
Issue number 1
Start page 11
End page 18
Publisher Elsevier Ltd.
Place of publication Amsterdam, The Netherlands
Publication date 2006-04
ISSN 1574-6267
Keyword(s) emergency nursing
clinical nursing research
clinical practice guideline
nursing assessment
Summary Introduction: There is wide variation in emergency nursing practice in terms of initial patient assessment and the interventions implemented in response to these patient assessment findings. It is hypothesised that written ED nursing practice standards will reduce variability in documentation standards related to initial patient assessment.

Aim: This study aimed to examine the effect of written ED nursing practice standards augmented by an in-service education programme on the documentation of the initial nursing assessment.

Method: A pre-test/post-test design was used. Initial patient assessment was assessed using the Emergency Department Observation Chart. All adult patients (>18 years) who presented with chest pain and who were triaged to the general adult cubicles were eligible for inclusion in the study. Random sampling was used to select the patients for the pre-test (n = 78) and post-test groups (n = 74).

Results: There was significant improvement in documentation of all aspects of symptom assessment except quality and historical variables: pre-hospital care, cardiac risk factors, and past medical history. Improvements in documentation of elements of primary survey assessment were variable. There were significant increases in documentation of respiratory effort, chest auscultation findings, capillary refill and conscious state. There was a significant 18.3% decrease in the frequency of documentation of respiratory rate and no significant changes in documentation of oxygen saturation, heart rate or blood pressure.

Conclusion: Written ED nursing practice standards were effective in improving the documentation of some elements of initial nursing assessment for patients with chest pain. Active implementation strategies are important to ensure effective uptake of written practice standards and the relationship between nursing documentation and actual clinical practice warrants further consideration using a naturalistic approach in real practice settings.
Language eng
DOI 10.1016/j.aenj.2006.03.004
Field of Research 111003 Clinical Nursing: Secondary (Acute Care)
HERDC Research category C1.1 Refereed article in a scholarly journal
Copyright notice ©2006, College of Emergency Nursing Australasia Ltd
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