Assignment: Quality of Nursing Documentation Reflection

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Assignment: Quality of Nursing Documentation Reflection

Please make me a two-page Reflection journal for this week for my project: Initiative to improve the quality of nursing documentation. Including references. APA 7th edition format.

It must include all of these:

1.The week’s goals- 14 points


  1. Evaluation of the project:      Initiative to improve the quality of nursing documentation. The project      was a success in terms of buy-in from the management and the staff. The      most important goal that was achieved was the promotion of compliance in      nursing documentation.

2.Activities and events that happened this week, including accomplishments and disappointments- 14 points

Explanation: After the project’s intervention of educating the staff on documenting the EKG interpretation, on pain assessment, and reassessment, and on the unit’s documentation guidelines, the project’s findings were shared with the target audience, the staff nurses. The findings were very positive that the chart audits came back 100 % complete in all aspects. The most significant disappointment this week is that the nurse educator who will do the chart audit monthly from August until December was detailed to another unit and that left me to ask my nurse colleagues to take on the responsibility. A very enthusiastic coworker eagerly wanted to do it.

3.Hurdles and barriers- 14 points

Explanation:  It’s a challenge for me to train my coworker to do the audit because in our department, nurses have numerous non-nursing roles, which denied both of us the time to do the training. It remains the source of disappointment for this week. The non-nursing roles are: We make appointments for the patients when the clerks go home at 3 pm. We get disrupted with too many phone calls unrelated to PACU and direct them to the areas they need to connect to. Most of the time, we transport patients. Nurses get the patients dressed when they are ready to go home, and most of the time, we transport patients.

Other barriers to the training are staff shortages (we have one nurse on orientation), and another one is starting in August., inconvenient places/times (Our unit opens at 5:30 am and closes at 8:00 pm if there is no admission from the recovery room) Monday to Friday, fatigue/inability to concentrate after working (We work 12-hour shifts), and family/personal commitments.

4.Project revisions or adjustments- 14 points

Explanation: It is a great milestone to have a nursing documentation project in our unit and this created a mark in the hospital.

5.Next week’s goals-

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Assignment: Quality of Nursing Documentation Reflection

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