Standardizing ICU Nursing Shift Notes


Standardizing ICU Nursing Shift Notes

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The purpose of this project was to see if the standardization of a nursing shift note increased the communication of important patient information between nursing and provider teams. The attending physician in the cardiothoracic intensive care unit (CTICU) stated critical patient information between shifts was missing in handoffs and inconsistent nursing notes. Providers cannot easily read all forms of nursing documentation for a summary of what is pertinent to patients. It was hypothesized a standardized note for handoff would increase the information providers could review before rounds and decrease the omission of critical data.

A review of the literature was done on handoff standards in critical care. Use of standardized handoff notes reported improved communication on patients’ overall plan, decreased adverse patient events and medical errors. CTICU providers and nurses gave input on critical pieces of handoff communication. A CNS was consulted on components to make the note usable in other ICUs. A template was developed in the electronic medical record for standardized handoff information. CTICU nurses were educated to use the template instead of unformatted progress notes.

Initial compliance of template use was high and early reports from the provider team included improved communication, receiving more information, and improved patient care. Nurses reported satisfaction with ease of use. A standardized note improved communication between providers and nurses with consistent handoff information. This feasibility study has future implications in expanding the use of this note to other ICUs to formally collect data on its functionality, and impact on communication and patient care.

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Carmine D’Angelo, BSN, RN; Jarvis McGrath, BSN; Rebecca Gooch, MD

Rochester General Hospital

Standardizing_ICU_Nursing_Shift_Notes.pdf (1293 kB)
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Standardizing ICU Nursing Shift Notes