Hybrid Charting Improves Documentation Compliance in a Comprehensive Stroke Center

Objective: To evaluate the neurological assessment (NA) and vial sign (VS) compliance rates of patients with ischemic stroke treated with IV alteplase (rt-PA) during the first 24-hours after therapy due to hemorrhagic conversion or other systemic bleeding. Background: Documentation errors may hinder the ability to provide and deliver quality of care to stroke patients. Transition of care for post rt-PA nursing assessments is documented in a hybrid fashion: on paper in the ED, and electronically in the Stoke Unit. Monthly audits illustrated employees were not abiding by the documentation policy, impacting the accuracy and consistency of NA and VS monitoring. Design/Methods: Retrospective data collection was performed between September 2015 to July 2016 on patients (n=60) who received t-PA in the ED. Cases were reviewed for charting compliance and identified as non-compliant if one or more NA or VS were missing, or failed to adhere to documentation policy. Descriptive statistics were performed. Results: There were 60 cases of ischemic stroke patients treated with rt-PA from September 2015 through July 2016. Of the sixty patients, 29 patients received rt-PA where eleven of the twenty-nine cases were compliant (37.9%). The rt-PA paper-version flowsheet intervention was introduced between February to July 2016, where thirty-one patients received rt-PA of which twenty cases were compliant (64.5%). Implementing a standardized rt-PA monitoring flowsheet resulted the compliance rate to increase by 26.6% (ρ=0.039) with time sensitive charting. Conclusions: The collaborative effort between the ED and neurology nurses to develop a user-friendly tool resulted in a significant improvement with NA and VS monitoring, which improved delivery of care for our stroke patients. As electronic documentation in medicine advances, it is imperative that one is conscientious of deviations in protocols because of inherent constraints of the EMR. Disclosure: Dr. Wright has nothing to disclose. Dr. Wright has nothing to disclose. Dr. Gonsalves has nothing to disclose. Dr. Paiva has nothing to disclose. Dr. Pine has nothing to disclose. Dr. Coleman has nothing to disclose. Dr. Surendranath has nothing to disclose. Dr. Thirunavukkarasu has nothing to disclose.