Background: Healthcare documentation not only allows for communication among healthcare providers and maintains patient care record keeping, it also archives essential information used to track, evaluate, and consider valuable healthcare interventions. When documented properly, this information can be used in research to assess international and national healthcare topics like standards of care, quality of care, complication and infection rates, and many more. When documentation is not complete ad comprehensive, a false representation can be made and a patient’s safety is at risk. The American Nurse Association suggests nursing documentation be clear, accurate, complete, and accessible, allowing nurses to be responsible and held accountable for their documentation. Foreground: The inpatient unit of interest for this project, like many other hospital units, demands several hours of direct patient care, potentially leaving little time for complete documentation. As a consequence, documenting on important aspects of a patient’s record, like the removal of any intravenous device (IVD), are missed or incomplete. When these pieces of information are missing, opportunities to provide accurate data regarding patients, fall short. Therefore, it was this project’s objective to influence staff nurses to be as comprehensive as possible when documenting overall, and to see an improvement on the removal of any IVD documentation after providing an educational in-service. Theoretical and EBP Support: Lewin’s Change Theory served as a supporting component in influencing and guiding the nurses of interest, transforming their care and making it a standard of practice when documenting on the removal of IVDs. In supporting this project’s development, the Johns Hopkins Nursing Evidence-Based-Practice (EBP) Model served as guiding feature in the specific steps of EBP in nursing. Methods: Once both Institutional Review Boards granted approval for this Quality Improvement project, chart audits were performed within a three-week time frame pre- and post- nurse in-service. The provided in-service was given to staff nurses, float pool nurses, and nursing students over an 11-day period. The in-service included pertinent aspects of documentation, steps to improve current practice, which was supported by current evidence, and time for discussion regarding potential barriers to complete documentation. Findings: A clinically significant improvement of 11% was seen in comprehensive documentation on the removal of IVDs on a specific surgical patient population. The findings of this project predictively aligned with literature that supports the use of health information technology, like the electronic health record, were data are accurately and efficiently collected, which can be used to generate knowledge that leads to improved outcomes. Although the practice improvement was seen in a limited amount of time, the direction was progressive, foretelling beneficial outcomes when these kinds of quality improvement projects are implemented.
