A Quality Improvement Initiative to Improve Nursing Clinical Documentation Quality in Hospital-Based Ambulatory Care Centers

Improving nursing clinical documentation quality in hospital-based ambulatory care centers presents a unique and multifaceted challenge for ambulatory care educators and leaders. Bunting & de Klerk (2022) describe clinical documentation as “the process of creating a written or electronic record that describes a patient’s history and the care given” (p. 1). At our hospital-based ambulatory care centers, clinical documentation education begins during orientation and is emphasized throughout the year. In addition to both live in-services and online modules, chart auditing is also completed by the ambulatory care nursing educator to assess and reinforce nursing clinical documentation quality. Chart auditing can be described as “a quality management tool…a systematic process to review patient care against defined and agreed criteria in order to identify practice gaps” (Ramukumba & El Amouri, 2019).
At our hospital-based care centers, three charts per nurse are audited every two weeks during orientation. Once nurses have successfully completed orientation, one chart per nurse per month is audited. Prior to 2024, feedback on audit results was not shared routinely with staff nurses. In 2023, our overall chart intake audit average dropped nearly two percentage points from the previous year. In February 2024, a new quality improvement initiative was begun with the aim of improving nursing clinical documentation quality. The first part of this initiative comprised of emailing each nurse in the department their complete chart audit for the month, along with their productivity numbers, which include the number of patients on whom an intake was completed, number of patients discharged, number of allergies reconciled, and number of vaccines given for that given month. The second part of the initiative titled “chart audit champions” was started. This initiative involved sending an email to all members of our department to highlight each nurse who received a 100% on their chart audit for that month.
Since beginning these initiatives, we have seen significant improvements in our nursing clinical documentation quality. The first month (February 2024) “chart audit champions” began there were 12 nurses who earned the designation. In September 2024, there were 36 nurses, a 33.3% increase. As a result of these initiatives, our overall chart intake average improved from 91.5% in 2023 to 94.7% YTD in 2024.