Improving Documentation

Publication Date

Spring 3-18-2026

College

Gordon E. Inman College of Nursing

Department

Nursing, School of

Student Level

Undergraduate

Faculty Mentor

Linda Wofford

Presentation Type

Gallery

Summary

Group 3: Improving documentation

Group members: Jamie Anderson, McKenzie Brinkley, and Lydia Mazengia

SPARK Summary

Our change project aims to improve documentation accuracy through the implementation of collaborative documentation practices. The collaborative documentation process actively partners clinicians and clients in interactions regarding assessment and service planning. Effective documentation skills are essential to patient safety, continuity of care, and prevention of medication errors; however, many healthcare professionals are not adequately documenting client interactions. We interviewed a pediatric clinic in Nashville, whose main communication issue is related to incomplete or delayed documentation. The implementation plan includes requiring all the staff attend meetings about not only how collaborative documentation works and its benefits, but also documentation standards. The clinic will achieve this over 10 weeks which consists of baseline audits during the first 5 weeks, training, implementation, and lastly evaluation. Feedback sessions to identify needed workflow adjustments will address the potential disruptions and time burden of the proposed change. After implementing these steps, we will conduct additional audits and staff surveys to assess impact. Audits will measure thorough, accurate, and complete documentation while the Mini Z burnout scale survey will evaluate attitudes toward documentation burden. Sustainability for collaborative documentation includes policy integration, onboarding education for new staff, and periodic audits to verify compliance. Our change project is expected to improve documentation, and in turn improve patient safety and care.

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