Learning outcome: By the end of this poster presentation, participants will be able to effectively implement a workflow-integrated, problem-based approach to provider documentation to improve quality and accuracy, thereby enhancing patient handoffs and overall patient safety.

Purpose: This project explores the implementation of a workflow-integrated, problem-based approach to improve progress note documentation quality and problem list accuracy in the neonatal intensive care unit (NICU).

Design: In this quality improvement project, a convenience sample of 17 neonatal nurse practitioners (NNPs) was evaluated. For time efficiency and problem list documentation, performance was observed over a three-month period pre-intervention from August 1 through October 31, 2023, and post-intervention from December 6 through March 6, 2024. For note quality, two notes pre-intervention and two notes post-intervention were compared.

Methods: Data retrieved from the EHR through reporting and manually with the PDQI-9 tool was analyzed using a Wilcoxon test with SPSS.

Findings: The use of the workflow-integrated, problem-based approach to progress notes improved total PDQI-9 scores from 40.5588 to 44.0588. The average total number of problems added to the problem list increased from 4.451 to 21.157.

Conclusions: Using the workflow-integrated, problem-based progress note in the NICU led to improved note quality scores and more active clinical problems added to the problem list. While time efficiency did not show an improvement, it is anticipated to improve over a longer period as providers become more proficient in the EHR changes.

Brady Urquhart DNP, RN

Appearances