Emergency Nurse Documentation Improvement Tool.
Nursing documentation for trauma resuscitation has improved significantly at our level I trauma center because of the introduction of our Emergency Nurse Documentation Improvement Tool (END-IT). The END-IT system was implemented as a performance improvement model and utilizes existing computer software. It provides quick computerized feedback to professional nurses when documentation of trauma cases needs further attention. The feedback is provided in written form and uses peer mentoring to improve accountability in documentation. The program has been successful and has decreased documentation omissions and mistakes by 21%.
Wainwright
Gail A
GA
St Luke's Level 1 Regional Resource Trauma Center, Bethlehem, PA 18015, USA.
Stehly
Christy D
CD
Wittmann-Price
Ruth A
RA
D004282:Documentation / Q000379:methods*; D016529:Emergency Nursing / Q000193:education / Q000458:organization & administration; D005568:Forms and Records Control; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D009104:Multiple Trauma / Q000628:therapy; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000193:education / Q000458:organization & administration; D010348:Patient Care Team; D018024:Peer Review, Health Care / Q000379:methods; D010414:Pennsylvania; D012151:Resuscitation / Q000451:nursing*; D012984:Software; D017749:Total Quality Management / Q000458:organization & administration*; D014193:Trauma Centers