Improving Medical Documentation Through Education

The aim of this DNP project was to develop an educational module about documentation for nurse midwives and nurse midwifery students. Formal education on documentation has been shown to improve charting practices for resident physicians when compared to those who received no training. Improved charting practices can reduce the risk of medical malpractice, which is common among obstetric providers. A recent survey of members of the American College of Nurse Midwives (ACNM) found that over 30% had been named as a defendant in at least one case. There is currently no specific formal training for student nurse midwives regarding their charting practices. Scenario-based learning modules have demonstrated effectiveness with individuals who have existing knowledge of a subject, and can be used for medical documentation education. Litigation among nurse midwives is increasing in the United States. Incidence of legal action increases commensurately with the number of births attended by practitioners. Incomplete or missing documentation of a case puts a provider at risk for being found negligent. The objectives of this project were to create a scenario-based educational module for nurse midwives and students with the intent of increasing their knowledge of defensive and effective documentation, pilot the module among practicing midwives and students, gain feedback from participants through a pre and post test module assessment, and disseminate the module to ACNM locally and nationally. The module was created using the Camtasia® program. Information was presented in a slide show video format with voice over narration. Module content was included based on data from literature review and content expert recommendation. The module was viewed by nurse midwives and students, who also completed a pre and post module assessment. Results indicate an improvement (p < .001) in participant scores by 28% after viewing the module. Feedback on the content and format of the module was elicited from participants with a free text question on the post module assessment. A revised module was then submitted to the ACNM for consideration for inclusion on the organization's website. A poster presentation of the project was presented to the local ACNM affiliate members. The module will be utilized in the nurse midwifery and women's health nurse practitioner graduate education programs at the University of Utah. Documentation is an important element of medical training and practice, and is the best defense for a provider in a medical malpractice case. This module provides basic elements of documentation training and could be expanded to provide more extensive training for nurse practitioner students as well as professional midwives. This module could also be used in its current state as an additional resource for educators teaching defensive medical documentation to reduce medical litigation.