Departmental collaborative approach for improving in-patient clinical documentation (five years experience)

The development and implementation of a postfall template to improve the content of provider documentation related to falls in the hospital setting

Patient falls are the focus of many hospital prevention and continuous improvement initiatives. This is due to the potential negative impact on patient quality and safety outcomes, cost of care, and litigation risk. The published literature includes an abundance of information regarding fall-prevention programs; however, there is a gap in the knowledge base pertaining to implications of what is documented by providers (physicians, nurse practitioners, physician assistants). There is concern that inadequate documentation may be associated with patient safety and quality issues. These include potential delays in the identification and treatment of fall-related injuries and increased legal risk. A routine analysis of submissions to the hospital's Safety Event Reporting System identified inconsistencies in provider postfall documentation. Because of the potential impact on patient care, safety, financial, and medical-legal implications, a project team was created to optimize the workflow and improve provider documentation as part of the comprehensive postfall program. This article describes the process of creating and implementing a postfall template to standardize and improve the content of postfall notes. The standardized template aligns with the organization's current initiatives to increase caregiver awareness of the impact of patient falls, and to improve patient safety and quality of care.