Authors: (including presenting author): :
Lau MS(1), Ip NL(1), Wong KY(1), Liu KH(1), Chan CH(1), Leung HW(1)
Affiliation: :
(1) Department of Medicine & Therapeutic, Prince of Wales Hospital
Keyword 1: :
Convulsion Event
Keyword 2: :
Nursing documentation
Introduction: :
Accurate documentation of convulsion events is vital for managing patients with seizure during hospitalization. However, inconsistent documentation practices by nursing staff often lead to gaps in clinical information,reduce effective communication with doctors.
Objectives: :
Aims to enhance nursing documentation of convulsion events by implementing a standardized documentation framework. The goal is to improve the accuracy and completeness of records, thereby fostering better collaboration among doctors and enhancing patient outcomes.
Methodology: :
A quality improvement initiative was conducted in a hospital setting involving nurses in the neurology ward(7A ward PWH). A standardized documentation template was developed, focusing on critical aspects of convulsion events, including onset, duration, semiology, and post-ictal state. Briefing sessions were organized to train nursing staff on the new documentation format and its importance in clinical practice. Pre and post implementation audits were conducted to assess changes in documentation practices.
Result & Outcome: :
The implementation of the standardized documentation framework resulted in a significant increase in the accuracy and completeness of convulsion records. Pre-implementation audits showed only 45% of convulsion events documented adequately, whereas post-implementation audits revealed an improvement to 85%. Feedback from nursing staff indicated a greater understanding of documentation requirements and increased confidence in reporting convulsion events. Enhanced communication between nurses and doctors was also observed, leading to improved care coordination and timely interventions for patients. In conclusion, standardizing nursing documentation for convulsion events effectively improves documentation practices and patient outcomes, highlighting the importance of structured formats in clinical settings. This initiative serves as a model for future quality improvement projects in healthcare.
