IMPLEMENTING AN EDUCATIONAL PROGRAM TO IMPROVE RECORD KEEPING PRACTICES IN HEALTHCARE

Document Type:Thesis

Subject Area:Management

Document 1

Poor documentation has resulted in inadequate healthcare services such as reduction in quality of life, pain, and suffering among patients. Aims: This paper object to establish an educational program to teach the nurses in healthcare how to keep excellent records in healthcare sectors that purpose to increase the awareness of the importance of adhering to recording keeping standard to improve quality of healthcare services in the hospital. Rationale: following the previous studies, the main areas of concerns are: First, lack of proper communication method among nurses and other clinical professionals which have failed to communicate vital information among them. Second, there is no standardized method in place for recordkeeping patient data. Change process: the project intends to use the Plan-Do-Study-Act (PDSA) model to guide the change. The project is scheduled to offers monthly sessions for eight months with the assistance of key stakeholders; senior nurses and State Claim Agency. Evaluation: the project will be gauged using PDSA assessment model. The general learning outcome will be assessed using an audit tool based on nurse documentation principles. Table of Contents Abstract 2 CHAPTER 1 INTRODUCTION 4 Introduction and Background: Recordkeeping 4 Problem Review 4 Aims and Objectives 5 Aims 5 Objectives 6 Planned Outcomes 6 Literature reviews 6 CHAPTER 2: METHODOLOGY 7 Context 7 Interventions 8 The education team 9 Rationale for selecting the Plan-Do-Study-Act (PDSA) change model 10 Advantages of PDSA model 10 Limitation model of PDSA 11 Methods for data collection 11 Interview 11 Questionnaires 11 Research 11 Analysis Plan 12 Quantitative formative assessment approach 12 Qualitative evaluation approach 12 Ethical consideration 12 CONCLUTION 13 The Project Impact 13 Funding 14 Conclusion 14 References 15 CHAPTER 1 INTRODUCTION Introduction and Background: Recordkeeping McDaid (2013), defined documentation as the process of recording and storing patient care prearranged and administered to a patient by professional nurses.

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According to Yontz et al. Health Service Executive (2012) observed that the exchange of accurate data in healthcare fortifies the delivery of excellent quality services to health care users. There is a need for a healthcare organization to maintain proper and standardized patient record keeping procedures. The purpose of the education program is to improve recording keeping practices at the Harrisburg State public hospital. Problem Review There has been a constant lamentation from the patient about the poor quality of services offered at the Harrisburg State public hospital. After conducting a vigorous investigation and research through interviews, questionnaire, and observation realized that poor documentation of patient's record is the main reason for poor quality of healthcare services at the Harrisburg State public hospital. The program will provide instruction and guideline on how to emulate good documentation practices, instructs and teach nurses how to record, communicate and share information among healthcare personnel.

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During the educational session, we will form an audit team which will be auditing the progress monthly at the start (November 2018) until at the end (April 2019). Planned Outcomes The planned outcome for our education program is that by the end of this education program, all nursing personnel to have attended at least five education sessions and learned the accepted documentation standards. Thus the project will have established improved responsiveness of the importance of record keeping and implanted a vigorous knowledge base on in effect means of interaction within the Harrisburg State Hospital. At the end of training, we opt to see a steady increase in quality of healthcare service offered at the hospital. More often nurses underestimate the importance of record keeping in an organization, improving patient care. As Prideaux (2011), suggested documentation of patient healthcare considered as a vital component of the comprehensive care of patients.

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McNamara, Joyce, and O’Hara (2010) indicated that an educational program must be readily established in healthcare organization to assist nurses in analytical reasoning and acute rational to elevate and uphold standards. There is a need to develop a positive learning environment where nurses are polished and motivated by the philosophies of quality record keeping (Parry et al. This education program will primarily focus to educate the nursing personnel at the Harrisburg State public hospital, the importance of proper record keeping standards. Clinical Nurse Specialist They will consist of four members who will deliver education talk. They will share their expertise in the area of documentation. State Claim Agency They consist of two members from the state authority department. They will give lectures on the legality, risk factors, and importance of upholding proper record keeping standards.

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Clinical Audit Team They consist of two audit member who will conduct auditing process to assess the progress of the project. Advantages of PDSA model PDSA is an extremely flexible model that can be used to scale up of interventions and used in union with observing activities to support sustainability. PDSA model provides a supportive mechanism for iterative development and scientific testing of changes in healthcare projects. Also, PDSA allows for early and effective change to the action plan, and it only focuses on focuses on changing clinical processes Limitation model of PDSA The main weakness of PDSA is that the model cannot be used as a standalone model. PDSA need to be used as part of the suite of QI method. Similarly, PDSA model is limited to small-scale test of change; it can’t be used in large change projects.

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Quantitative formative assessment approach The assessment program will be initiated at the beginning of education program to assess the improvement and help the training to the team to adjust priorities. Using audit tool, the clinical auditor will randomly select the sample of clinical records and evaluate progress. Qualitative evaluation approach Nurses will be grouped and given a chance to discuss record-keeping practices. In their views, they will be given the opportunity to ask questions, make the suggestion and formulate the action plan to improve documentation process. Ethical consideration Before commencement of this project, data collection, analysis, and findings of this project proposal submitted to quality assurance and ethical the organization's ethics committee. Variation in the quality of hospital records is always uniformly characteristic of all professions. There is more emphasis on the proficient often on local concern rather than on the great executive approach.

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Funding Improving recording keeping practices and the introduction of the monthly educational program for the nurse at the Harrisburg State National Hospital will not be possible without the initial cost of implementation. The plans for funding the project will include working closely with grant writers employed at the Harrisburg State Hospital. Conclusion In summary, the establishment of this educational program will teach the nurses in healthcare how to keep excellent records that purpose to increase the awareness of the importance of adhering to recording keeping standard to improve quality of healthcare services in the hospital. Adaptation and Barriers to Adoption of Electronic Health Records by Nurses in Three Government Hospitals in Eastern province, Saudi Arabia. Perspective in Health Information Management. McDaid, S. The recovery ethos: towards a shared understanding.  Irish Journal Of Psychological Medicine, 30(04), 285-288.

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Sembi, P. Implementing change: an autobiographical case study of introducing a technology innovation within a West Midlands HEI.  Journal Of Further And Higher Education, 36, 109-125. Top, M. Yilmaz, A. Zinn, J. L. Schumacher, E. J. Perioperative Nurse’s Attitudes Toward the Electronic Health Record.

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