Improving Stroke Documentation on a Stroke Unit

The aim of this project is to improve adherence of stroke documentation per stroke protocols on a stroke unit at an acute hospital setting through nursing education and EPIC modifications. A comprehensive retrospective data collection was done to determine the inconsistencies of nursing documentation per organizational protocols. Firstly, a randomized sample of 163 stroke patients (Site 1 = 98; Site 2 = 65) was generated for retrospective data collection. For this project, the main focus was Site 1 (n = 98). The sample from Site 1 consisted of 4 types of stroke patients, which were patients who either received alteplase (TPA= 19); did not receive alteplase (NTPA= 34); had Intracerebral Hemorrhagic Stroke (ICH= 30); or were suspected of stroke/ Transient Ischemic Attack (TIA= 15). Next, stroke chart audits were done to determine whether or not the nursing documentation was consistent per stroke protocol. The goal of this retrospective data analysis was to recognize areas where there are charting inconsistencies; lacks of adherence to the organization’s stroke protocols, and recommend interventions to improve nursing stroke documentation. Results from this retrospective data analysis demonstrate the need to educate nurses on the importance of accurate and consistent documentation along with the legal implications if non- compliant with standard protocols. In addition, there is a need to modify EPIC to enforce stroke protocols and increase nurses’ compliance rates