Date of Award
Spring 2025
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
Committee Chairperson
Jacquelyn Owens, DNP, CRNP
Committee Member
JJacquelyn Owens, DNP, CRNP
Committee Member
Irma Yehuda, DNP, CRNP
Abstract
Abstract
This evidence-based quality improvement project addresses problematic documentation noted on a Maternal-Fetal Medicine Antepartum Testing Unit. The quality of patient care and billing practices can be impacted by minor “typos” that exist in electronic medical records (EMRs), creating a significant challenge for those who use them. This project evaluates key areas contributing to inaccuracies in medical records using chart audits to identify frequency and types of errors. Educational sessions via PowerPoint were used to discuss charting practices. A designed framework for ongoing training and support emphasizes the importance of accurate documentation and specific areas of concern via audits to reduce documentation errors while improving charting accuracy and billing practices. A systematic QI project fosters a culture of accuracy in medical documentation and subsequently improved quality of patient care. A significant reduction in charting errors was observed following the educational sessions. Post-intervention audits demonstrated a marked improvement in documentation accuracy, with fewer instances of missing data and other common errors. This highlights the effectiveness of targeted educational interventions in mitigating documentation errors and fostering a culture of quality improvement within the healthcare setting.
Recommended Citation
Mullins, Morley, "Decreasing Charting Errors On an Antepartum Testing Unit" (2025). West Chester University Doctoral Projects. 316.
https://digitalcommons.wcupa.edu/all_doctoral/316