Standardized Neonatal ICU Progress Note Template and Feedback System: A Clinical Documentation Improvement Initiative

Abstract

Introduction This quality improvement (QI) initiative aimed to improve the clinical documentation of daily progress notes in the neonatal intensive care unit (NICU) by applying a standardized documentation template and conducting regular cycles of audit and feedback to ensure compliance and improvement. Methods Firstly, to better assess documentation practices impacting patient care, members of the NICU auditing team identified seven key points in medical records. These points were then used for the audit of 30 randomly selected "progress notes" for infants admitted to the NICU between January and June 2022. We introduced a new standardized progress note template in the NICU based on the initial seven key points considered essential in NICU documentation. Subsequently, we educated the staff on the latest changes and their impact on patient care delivery. Also, we raised awareness among the NICU staff regarding the quality improvement project we were running and the requirement to adopt the new standard template. We also ensured that everyone had access to the new template. The QI team analyzed NICU progress notes every three months from October 2022 to July 2023; 45 notes were reviewed per cycle, a total of 135 notes. With each cycle, we took feedback from NICU team members regarding the deficiencies and opportunities for improvement in clinical documentation and encouraged adherence to key points. A template for the specific needs of the NICU was redesigned based on feedback received from all stakeholders on how to reduce the obstacles in adopting and retaining compliance with the new template. Results Compliance with the "key elements" of documentation improved dramatically after introducing a new template and feedback system. In the final cycle, the overall compliance was 81% (p<0.0001), well above our initial target of 60% compliance. Conclusion A unit that implements targeted audit-and-feedback measures relevant to the clinical team requirement can substantially and consistently improve documentation.

Keywords: clinical documentation audit; clinical documentation improvement; errors in documentation; neonatal care; neonatal intensive care unit (nicu); nicu documentation; pediatrics and neonatology; plan-do-study-act (pdsa); quality improvement and patient safety; quality improvement projects.

Figure 1. Ishikawa diagram of the project