Introduction: Documentation templates supported the implementation of HIRAID, a validated framework that supports nurses in assessing and managing patients in emergency departments in rural Australia using a strategy informed by behavior change theory. The study aimed to determine whether the implementation of HIRAID improved the accuracy of nurses' documentation across a large rural health district.
Methods: A Quasi-experimental pre-post study design was conducted across 10 rural emergency departments between November 2020 and November 2021, with HIRAID implemented in February 2021. Retrospective audit of clinical documentation occurred 3 months pre-implementation and repeated at 6-months post. Based on power analysis and a sampling framework, records that met study inclusion were randomized for audit. Documentation accuracy was evaluated, using a modified D-catch instrument, assessing quality and quantity by an experienced research nurse. Data were analyzed with descriptive and inferential statistics.
Results: A review of 222 records (110 pre/112 post), demonstrated an improvement in initial ED nursing assessment documentation. Audit scores increased significantly for quantity of documentation across all areas, in particular history (P < .001) and red flags (P < .001), with a 27.1% increase in all red flags recorded. The quality of documentation also significantly improved across all areas, most notably in history (P < .001) and assessment (P < .001).
Discussion: Implementation of HIRAID demonstrated a sustained improvement in the quantity and quality of emergency nurse documentation. Improved documentation accuracy is key to informing and evaluating ongoing care and supporting communication and continuity of care, and is essential to patient safety.
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