From Documentation to Discharge: Standardising a nursing proforma to improve patient flow and support patient centred care

From Documentation to Discharge: Standardising a nursing proforma to improve patient flow and support patient centred care

Introduction:

High quality nursing documentation is essential for multidisciplinary team (MDT) decision making, discharge planning and supporting patient flow. Within an Older Persons Unit, inconsistent documentation and structure created challenges accessing key clinical information, delaying care coordination. A Quality Improvement Project (QIP) introduced a standardised SmartPhrase aligned with Comprehensive Geriatric Assessment (CGA) domains to improve documentation quality, consistency and accessibility with the overall to support to support patient centred care and flow.

Methods: 

Following MDT consultation, a standardised nursing documentation SmartPhrase was co-designed and piloted on a older persons ward with seven nurses of varying clinical experience. Feedback from nurses and MDT members informed further development and refinements before ward wide implementation, following the PDSA approach.  Evaluation included documentation audits and pre and post implementation MDT surveys assessing documentation quality, accessibility, consistency and usefulness for clinical decision making and discharge planning.

Results: 

One week after implementation, documentation audit demonstrated 96% compliance with SmartPhrase use. Compared with baseline, MDT survey responses demonstrated improvements across all evaluated domains, including documentation consistency, accessibility and clinical detail, positively supporting CGA, discharge planning and confidence in the accuracy of nursing documentation. Qualitative feedback reported that key patient information was easier to locate, documentation better reflected current patient needs and the SmartPhrase improved clinical reasoning and discharge coordination. Overall, 95% of respondents supported wider implementation across the unit, with 5% expressing a neutral view.

Conclusion: 

The standardised SmartPhrase improved the quality, consistency and accessibility of nursing documentation while enhancing MDT decision making and discharge planning for older adults. High compliance demonstrate that this low cost digital intervention is feasible with potential for wider implementation across inpatient services. There is acknowledgement for further PDSA cycles to continue to develop and optimise the SmartPhrase and a need for further education to support nursing development of clinical documentation.