Problem Statement

Care plans had been highlighted as an area requiring corrective action in the 2013, 2016 and 2019 Health and Disability Service Standards certification audits.

Creating accurate documentation and patient-centred care plans is an essential part of all health professionals’ work and is integral to their meeting competencies under the Health Practitioners Competence Assurance Act 2003.

Over the past 12 months, there has been a big drive within CM Health around the ‘Daily Assessment and Plan of Care’ form, which has been used by medical and surgical nurses following its rollout in 2017. However, audits have highlighted poor compliance and understanding of it.

What are we trying to achieve?

Our goals are to:

  • standardise clinical nursing documentation in patient notes
  • reduce unnecessary documentation
  • meet Health and Disability Service Standards for care plan documentation
  • increase education around and improve compliance with the ‘Daily Assessment and Plan of Care’ form.

What have we done?

In response to corrective actions identified in the 2016 certification audit, four forms were developed and rolled out across the organisation between July 2017 and March 2018:

  • ‘Patient Information on Admission’
  • ‘Patient Handover’
  • ‘Daily Assessment and Plan of Care’
  • ‘Discharge Planning’.

A pre, post and follow-up audit was completed with respect to the ‘Daily Assessment and Plan of Care’ form, to evaluate compliance with the form (including legal and best practice requirements) and to gain user feedback. These audits showed a clear improvement in clinical nursing documentation. However, they also identified other areas that required further training and improvement.

A big drive around education for nursing staff was completed through presentations, information packs and the involvement of nurse educators and plan of care champions. Targeted teaching sessions for each area were completed between December 2018 and February 2019. Small regular audits were also completed during this time to identify any additional issues at ward level.

A larger-scale audit focused on the corrective actions was completed in early 2019. Common themes, results and recommendations were presented and shared with relevant groups, clinical nurse directors, charge nurse managers and nurse educators. Improved compliance was seen in most areas. Wards have been encouraged to continue to monitor clinical nursing documentation, using an audit tool that was provided, and to liaise with nurse educators and plan of care champions for further training as needed.

In the background, work is also being undertaken with the Healthy Together technology team to see if it is possible to create an electronic version of this form.

What did we find?

Initial audits post-implementation of the ‘Daily Assessment and Plan of Care’ form showed an improvement in clinical nursing documentation. However, there was still a lot of room for improvement with respect to completion and understanding of the form.

Following a big drive around education and training, most recent audits in the medical and surgical wards have shown a significant improvement in the completion of the form, and in staff’s understanding and compliance with legal and best practice requirements.

How did we make a difference?

There has been a major improvement in clinical nursing documentation in the medical and surgical wards.

Where to from here?

As a number of forms continue to go electronic, work will continue on developing an electronic version of the ‘Daily Assessment and Plan of Care’ form.

Paediatric and mental health were identified as areas for improvement in the 2019 hospital certification audit, so development of specialised care plans for these areas will be the focus over the next 12 months.

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