Standardised care plans for in hospital stroke care improve documentation of health care assessments
- 14 July 2015
- journal article
- Published by Wiley in Journal of Clinical Nursing
- Vol. 24 (19-20), 2788-2796
- https://doi.org/10.1111/jocn.12874
Abstract
To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record. Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital. Quantitative, comparative. Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record. Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.This publication has 21 references indexed in Scilit:
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