Improving Clinical Documentation Compliance Pre-Gastrointestinal Endoscopy Procedures Through the Use of an Endoscopy Checklist

Abstract

Production pressure in endoscopy units, to avoid procedural delays, can lead to documentation gaps that pose a patient safety risk. Fast-paced, high-volume endoscopy units within a 673-bed academic medical center, incomplete and illegible documentation were identified during a 2018 Joint Commission survey. Pre-procedure safety checklists help ensure accurate clinical handovers. Checklists promote team communication that includes the patient to have complete and relevant information to perform a safe procedure and speak up to identify discrepancies. An endoscopy-specific safety checklist was used by the procedural team immediately pre-procedure. This quality improvement project used Plan Do Study Act cycles to incorporate changes suggested by users. Chart audits were conducted pre- and post-pilot. The results showed significant improvements in physician documentation completeness and legibility, suggesting the checklist prompted clarification of documentation and communication between the nurse and the physician. Nursing assessment saw a 27.1% improvement, suggesting clarification of clinical handover between the admitting and procedural nurses. Improved communication was perceived by staff. This project showed how a standardized tool to promote team communication and clarification of discrepancies pre-procedure can contribute to prevention of errors.

Audit of Documentation of Chest Drain Insertion Procedures Before and After Introduction of a Chest Drain Pro forma

“…In a recent study, improvements in clinical documentation were achieved for endoscopic procedures using an endoscopy checklist. 3 Apart from improving patient safety, well-designed, person-centered endoscopy checklists also assist in auditing clinical performance and in more accurate coding and billing for the services provided. 4 Luton and Dunstable University Hospital is a 650-bed facility providing secondary-level healthcare to a population of over 400,000.…”