The quality improvement practice gap I identified in my nursing practice or organization involves the timely documentation of patient care activities. In this case, nurses are not consistently documenting their patient care activities within the time frames outlined by our institution policies and procedures. This is resulting in an overall decrease in accountability as well as communication regarding a patient’s health status between members of the healthcare team. It is also causing delays in treatment due to missing information that could have been documented earlier on.
Briefly describe the quality improvement practice gap you identified in your nursing practice or organization. Be specific.
Improving timely documentation would contribute to improved patient outcomes, increased efficiency, and better communication among healthcare professionals. To address this gap, I proposed implementing a standardized electronic medical record system that clearly outlines when specific tasks should be completed by nurses and empowers them with tools to help them do so more efficiently. Furthermore, nurse managers need to be aware of any discrepancies between policy expectations and actual performance among staff members and provide feedback/support as needed to help fill any gaps they may find. Finally, all members of the healthcare team should work together collaboratively on patient cases with frequent check-ins amongst nurses/physicians/etc., which will ensure no important details are overlooked or delayed for too long during the process of providing care to patients.
Overall, addressing this quality improvement gap will result in greater accountability from staff members at all levels throughout our health system while simultaneously improving access to quality care for our patients through enhanced communication practices and improved medical records management capabilities.
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