Clinical Documentation Quality Improvement Project - Specimen Collection in the Emergency Department

Abstract
Purpose: A clinical documentation improvement (CDI) project was aimed at improving emergency department (ED) registered nurses (RN) and techs documentation of blood and urine specimen collection using the electronic health record (EHR) specimen collection documentation (SCD) flowsheets.
Methods: ED RNs and techs were provided with documentation improvement training in the form of a short video, SCD tip sheets, and at-the-elbow training sessions. The Plan Do Study Act (PDSA) framework was utilized to monitor iterative change over time and reinforce training. At baseline and during each of the three PDSA cycles, data was collected to study SCD use and accuracy when documenting blood and urine specimen collection. Changes implemented to reinforce documentation in the SCD flowsheet included ED nurse manager communicating importance of accurate documentation, replenishing tip sheets throughout the department, and ongoing at-the-elbow training.
Results: The CDI training materials were sent via email to 46 ED RNs and techs; 37% indicated they viewed the training video and 70% participated in at-the-elbow training. Post-implementation showed a 16% increase in the use of the SCD flowsheets over baseline for documenting blood and urine specimen collections. Blood documentation increased by 17% and urine documentation increased 15%. Although there was an overall increase in SCD flowsheet use, accuracy of blood specimen collection documentation did not improve whereas urine documentation accuracy did improve.
Conclusion: CDI efforts improve documentation of blood and urine specimen collection in SCD flowsheets of the EHR. Training methods were effective with at-the-elbow training sessions being well received by most. Participant feedback identified opportunities to improve accuracy of documentation with enhancements to the EHRs discrete data fields for location of the blood draw. Continued specimen collection documentation improvement has the potential to impact nursing practice through improved data collection. Improved data collection has implications for monitoring patient outcomes and increased revenue.