Abstract
Background: Exceptional communication among medical teams is imperative for ensuring optimal patient care. Note documentation is a critical part of this communication. Our department encounters patients with a wide array of respiratory needs and therefore is responsible for generating a diverse set of notes. Our progress note documentation had largely been in a free form fashion. We discovered several inconsistencies in the quality. Some notes depicted patient care in a great detail while others lacked essential information, potentially influencing other medical teams’ decision-making. Our department sought to make a change that would lead to more comprehensive and user-friendly notes.
Methods: Standardized note templates were created along with smart phrase accessibility in order to improve note quality and consistency. The note templates were attainable individually as well as from a drop-down menu. Each note consisted of three sections that were specific to different types of respiratory care. A survey was provided to the department to investigate whether the therapists preferred the new templates or if they favored writing notes in a free form. They were also encouraged to provide feedback.
Results: Out of the 69 RRTs approached with our survey, 55% responded. Out of the 55%, 97% were in favor of utilizing note templates. Supportive comments included improved note consistency and efficient documentation. They also expressed that the templates served as a checklist and helped ensure that their documentation was detailed and complete. Only one concern was mentioned and it revealed some aspects of the automatically populated content, such as history of present illness, occasionally contained inaccuracies. Comments provided also led to a request and subsequent introduction of a new template for patients with laryngectomies.
Conclusions: The institution of smart phrase note templates achieved our goal of providing a platform to improve note integrity and consistency. The survey results revealed an overwhelming support for the templates in comparison to our previous free form notes. The smart phrases and note templates were accepted by therapists for their ease of use and time-saving potential. Theoretically, they are also able to enhance the communication among medical teams. We anticipate them being very helpful to a newly hired staff since they distinctly depict patient care expectations set by our respiratory care department.
Footnotes
Commercial Relationships: None
- Copyright © 2024 by Daedalus Enterprises
