Improving Nursing Documentation in Patients With Sudden Cardiac Arrest Requiring Cardiopulmonary Resuscitation (CPR) in Long Term Acute Care

Abstract

Healthcare documentation is a very important required task when working in any healthcare setting. From every patient encounter, prescription refill, and laboratory testing; all healthcare providers are required to document. As a Nurse, accurate documentation is vital in improving patient safety and quality of care. In emergency situations, such as a sudden cardiac arrest requiring cardiopulmonary resuscitation, precise documentation is rarely accomplished, due to the hectic nature of the patient's health status. In many circumstances, healthcare providers have witnessed the designated nurse attempting to document interventions on a napkin, whiteboard, or glove. The patient primary nurse is responsible for documenting a narrative note in the patient chart after the incident. The subjective nature of the nursing narrative note after CPR is often inaccurate, incomplete, or lacks details. Several research studies have highlighted the significance of CPR, the assessment of time keeping roles in cardiac arrests, and the evaluation of nursing documentation. This research study will analyze and provide possible solutions to the challenges faced by Nurses in long term acute settings during the documentation process on patients with sudden cardiac arrest requiring CPR. This study will evaluate, anonymous and randomly extracted, narrative notes from patient�s charts. The analysis will identify a CPR documentation template that can be implemented to reconstruct and improve the documentation process. This effort will promote efficiency and accuracy in capturing, analyzing, and reporting of data in resuscitation science to help improve patient outcomes and workflow.