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Data Manager auditing infusion forms consistently find the incomplete source documentation found. Incomplete source documentation places the risk of the hospital during the tests required for accreditation and contradicts the aim of the institute to submit quality data in order to optimize clinical decision-making for the benefit of its patients.
Data Manager used for six months of paper data acquisition tools to document six different types of incomplete source documentation. Colorful, high-impact charts were designed to present data about the frequency of missing documentation and incomplete documentation types by hospital unit. The hospital program leadership has checked the charts weekly. The Nurse Manager checked the diagrams after the first three months and identified a data surveillance improvement. The Supervisor of the Data Managers touched the hospital nurse educator and offered to provide a pedagogical in service for soil nurses to understand the species of incomplete documentation. Then one of the three hospital units was provided with a pedagogical service. Data Manager continued to collect data for another three months.
The project was limited in the long term and data managers did not collect data long enough to measure a significant change in source documentation quality after training in the service on the nursing unit. The conductive lead was no direction on which steps should be taken after the project to improve source documentation quality. Data managers expressed frustration with their inability to improve the data acquisition procedure itself and also with the difficulty of initiation of the change about hospital units and management level.
Data Manager Created Tools with Custom Paper Data Setting to track the incomplete source documentation for a period of six months. After a pedagogical intervention, there was not enough data to make meaningful statistical conclusions. The lack of involvement of the commissioning of hospitals and the most important nurse manager was an important limitation. Since the review source documentation for the submission of the CIBMTR was already part of the Data Manager's workflow, the quality project required a minimum time and required a few materials. The Paper Data Collection tools can be easily replicated for use with other institutions.
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