Improving myocardial infarction documentation in the emergency department

Patient documentation is an essential component in nurses' daily activities; further, data found within nursing documentation are key to identifying patients' needs, acuity level, continuity of care, and quality-improvement measures. Unfortunately, medical records often lack adequate documentation, which are linked to failure in detecting changes in the patient’s clinical condition. Nowadays, in an effort to improve patients’ quality of care and outcomes, electronic medical records are being integrated into the healthcare system. These computer systems usually provide template guidelines that make nursing documentation more effective. The purpose of this project was to develop, implement, and evaluate the effectiveness of in-service classes and chart audits for improving nurses’ compliance with the AMI template while enhancing completeness of AMI documentation. Visual-based adult learning theory and Knowledge-to-Action Translation framework guided the project development. The primary investigator used a survey and in-service classes to assess emergency care nurses' knowledge with respect to AMI documentation, followed by pre/post chart audits to evaluate the effectiveness of each intervention. After completion of this project there was an increase in compliance with the emergency care AMI documentation template. Such findings reinforced the use of short-duration in-service classes and visual-based learning techniques as effective approaches to quality-improvement measures. This project contributed to the limited evidence-based literature regarding AMI documentation.DNPIncludes bibliographical reference