Reducing Patient Incidents Through an Improved Nursing Documentation in Elderly Care

Abstract

Falls, unplanned hospital visits, and pressure injuries are common occurrence in elderly home care facilities. To reduce these incidences, we aimed for 100% compliance of care home staff using an improved nursing documentation. The main intervention of this proposed quality improvement project is the implementation of SOAP (Subjective, Objective, Assessment, Plan) method of documentation in the resident’s electronic medical records for care home staff to utilize per shift with proper teaching and training.

The model for improvement framework and PDSA (Plan, Do, Study, Act) cycle will be used in testing, developing, and evaluating the proposed interventions to see if ideas will work in accomplishing our aim. Care home resident and staff will benefit in utilizing SOAP method of documentation in recognizing impending harm to elderly as well as assisting staff in a structured and organize way of writing nursing documentation respectively.