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DOI
https://doi.org/10.63853/CYFO7486
Description
QUALITY IMPROVEMENT
Background: An initial internal pilot audit of patient charts, performed by the Plano psych RN team within the Emergency department in November 2024 revealed significant gaps in documentation compliance for behavioral health patients. Many areas of required charting were found to be incomplete, partially completed, or inconsistently documented across disparate sections of the electronic medical record. This fragmentation not only impedes the ability to efficiently locate critical information but also fails to meet the documentation standards outlined in Children’s Health organizational policies. These deficiencies pose risks to continuity of care, clinical decision-making, regulatory compliance, patient and staff safety, ultimately underscoring the need for a targeted quality improvement initiative to enhance documentation practices and ensure alignment with institutional requirements.
Methodology: Methodology: The initial pilot audit was conducted using a standardized Excel spreadsheet to track the completion and compliance of required documentation across behavioral health patient charts by the Psych RN team. Data was submitted monthly from the Psych RN team to the Psychiatry Clinical Quality Improvement Consultant, who compiled and analyzed findings for dissemination to relevant stakeholders. Following the pilot phase, a streamlined data collection tool was developed in collaboration with accreditation partners using the GetWell Rounding platform. The new survey format facilitated real-time feedback and supported targeted interventions to address documentation gaps and reinforce compliance with organizational standards. In addition to the new rounding format, the Psychiatric RN team implemented in-person chart audits in collaboration with direct care staff to assist in an increase in charting compliance.
Outcomes: Following the implementation of the GetWell Rounding survey, charting compliance improved significantly—from an initial baseline of 28% to sustained rates exceeding 90% over several consecutive months. Department and unit leaders reported that the enhanced data collection process was instrumental in identifying targeted opportunities for staff education and workflow improvement. Additionally, primary staff demonstrated increased completion of behavioral health documentation prior to Psychiatric RN intervention, reflecting greater awareness and understanding of required charting standards. This proactive engagement contributed to a more consistent and compliant documentation culture across both Emergency Room and Inpatient settings.
Publication Date
11-24-2025
Disciplines
Pediatric Nursing
Recommended Citation
Pump, Sara; Spain, Lauren; Kasenic, Virginia; Talent, Meagan; Stewart, Alivia; Shaw, Carrin; Gautreaux, Chad; Cousin, Dori; Allen, Ronesea; and Rowe, Jonathan, "Precision in Practice: Subject Matter Expert Integration to Support Excellence in Population-Specific Documentation" (2025). 2025. 38.
https://scholarlycollection.childrens.com/nursing-anf2025/38
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This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
