Documentation in a PICU setting: Is a checklist tool effective?

Abstract

Objective: To compare and contrast nursing compliance with, and completion of, two versions of a nursing care management form. The audit highlights areas and levels of compliance and non‑compliance and provides the foundation for further document development.

Design: A retrospective chart audit was undertaken comparing completion levels of a previous nursing checklist (form A) and a revised and updated checklist document (form B).

Setting: A paediatric intensive care unit (PICU) at a major metropolitan paediatric hospital.

Subjects: All available medical records containing the checklist of those patients discharged from PICU during the months of November 2009 and February 2010 were audited.

Main outcome measures: Levels of completion of both versions of the form and individual items were low.

Results: Compliance levels with document completion improved following the introduction of the form B, although poor completion remained a major issue. Up to 70% of nursing shifts recorded no information on the checklist document. Compliance levels were not affected by age, length of stay, or severity of illness.

Conclusions: The checklist forms were largely left incomplete, although an improvement in completion was noted with the introduction of the new checklist (form B). This raises questions about the appropriateness of the forms and their applicability to clinical practice.