title: Improving nursing documentation for private-duty home health care.
abstract: Private-duty, home health care agencies have struggled in assuring compliance with accurate and complete nursing documentation. In this descriptive study, the author reports on an improvement and innovation project in a private-duty, home health care agency aimed at improving nursing documentation, as measured in chart review audits. Initial strategies were directed toward revising the documentation system, with implementation of a flow record, and conducting group nurse education. These efforts had a minimal effect on improving documentation compliance. A major, multifocus strategy was then implemented. The educational component stressed pre- and posttest. The chart audit tool was revised to track individual nurse behaviors. Nurses were mentored when documentation did not meet standards. Lastly, the nurse job description and corresponding performance appraisal document were revised to clarify nurse responsibility and strengthen nurse accountability; progressive discipline was initiated when warranted. Significant and sustained improvement was subsequently realized.
authors.affiliation: Clinical Services, Saint Thomas Home Health Agency, Inc., Nashville, TN, USA.
authors.forename: E L
authors.initials: EL
authors.lastname: Borchers
mesh_terms: D004282:Documentation / Q000379:methods / Q000592:standards*; D004650:Employee Performance Appraisal / Q000379:methods*; D005568:Forms and Records Control; D018575:Home Care Services, Hospital-Based / Q000592:standards*; D006801:Humans; D009737:Nursing Records; D009744:Nursing, Private Duty / Q000592:standards*; D011785:Quality Assurance, Health Care; D015144:Southeastern United States