Essential Documentation Elements: Quality Tool for the Emergency Department NurseNielsen, Gayla RN, PhD; Peschel, Laura BS, CPHQ, CPMSM; Burgess, Ann BSAdvanced Emergency Nursing Journal: April/June 2014 - Volume 36 - Issue 2 - p 199–205 doi: 10.1097/TME.0000000000000020 Cases of Note Abstract Author Information Abstract The use of real-time feedback about documentation may improve compliance with best practice standards, provide immediate rewards for high-quality documentation, and present an opportunity to make instantaneous improvements to the documentation. This project was conducted in a large, urban emergency department (ED) to enhance patient safety, improve documentation quality, and increase timeliness of documentation. The PDSA (Plan, Do, Study, Act) model was used to develop a valid and reliable process to enhance the clinical care process. Passive electronic visual cues with real-time feedback to the clinician were developed. Between March 2011 and 2012, a total of 89,521 ED records were reviewed for compliance with 16 documentation elements. Documentation improvements were achieved with seven elements. There was a slight decrease in compliance for four elements, and equivalent levels of compliance in five elements were noted. Staff reported that the program was helpful in providing reminders and that passive cues were more helpful than hard stops. Areas for software refinement were also identified. This process demonstrated that the data collection burden was reduced and sampling error was eliminated. Although additional study is needed, the electronic health record can provide passive visual cues to enhance nursing care, improve regulatory compliance and data collection, and provide immediate feedback to the clinician. Author Information Emergency Department (Dr Nielsen) and Process Improvement (Ms Peschel), Cedars-Sinai Medical Center, Los Angeles, California; and Arch Health Partners, Poway, California (Ms Burgess). Corresponding Author: Gayla Nielsen, RN, PhD, Emergency Department, Cedars-Sinai Medical Center, 8700 Beverly Blvd, #1103-NT, Los Angeles, CA 90048 (firstname.lastname@example.org). Disclosure: The authors report no conflicts of interest. © 2014 by Lippincott Williams & Wilkins.