Abstract

With the advent of electronic health records, nursing documentation has declined in quality. Poor documentation exposes patients to safety risks. Nursing documentation is subject to legal standards set by the Texas State Board of Nursing. A DNP scholarly project was designed to create a learning and safety intervention to train student nurses to provide correct documentation before entering clinical settings. The goal of this project was to prepare nursing students to provide quality documentation that fulfills the legal standard to attempt to correct the current deficiencies seen in practice and promote patient safety. For this project, the students took a pretest related to nursing documentation, were presented with didactic education for nursing documentation, attended a simulation where they encountered a problem, practiced documenting the situation, and completed a posttest. The students were allowed to collaborate and were given instructor feedback. The project increased students' knowledge and confidence in their ability to provide quality nursing documentation, thereby improving patient safety and regulatory compliance. Due to the success of the intervention, the stakeholders decided to turn the training into an interactive module that will be completed every semester prior to clinical attendance.

Date of publication

Fall 12-8-2022

Document Type

DNP Scholarly Project

Language

english

Persistent identifier

http://hdl.handle.net/10950/4129

Committee members

Dr Cheryl Parker, Dr Laurie John, Dr Kandice Perez

Degree

Doctor of Nursing Practice

Included in

Other Nursing Commons

Share

COinS