ArticleCureus2024
Standardized Neonatal ICU Progress Note Template and Feedback System: A Clinical Documentation Improvement Initiative.
Article in Cureus, 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
1 citing paper in PubMed.
- Edge-Hosted LLM-Assisted NICU Discharge Summary Generation: Field-Level Evaluation Using a Clinician-Defined Rubric.Healthcare (Basel, Switzerland) · 2026Article
Corrections and comments
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Authors and funding
5 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Introduction This quality improvement (QI) initiative aimed to improve the clinical documentation of daily progress notes in the neonatal intensive care unit (NICU) by applying a standardized documentation template and conducting regular cycles of audit and feedback to ensure compliance and improvement. Methods Firstly, to better assess documentation practices impacting patient care, members of the NICU auditing team identified seven key points in medical records. These points were then used for the audit of 30 randomly selected "progress notes" for infants admitted to the NICU between January and June 2022. We introduced a new standardized progress note template in the NICU based on the initial seven key points considered essential in NICU documentation. Subsequently, we educated the staff on the latest changes and their impact on patient care delivery. Also, we raised awareness among the NICU staff regarding the quality improvement project we were running and the requirement to adopt the new standard template. We also ensured that everyone had access to the new template. The QI team analyzed NICU progress notes every three months from October 2022 to July 2023; 45 notes were reviewed per cycle, a total of 135 notes. With each cycle, we took feedback from NICU team members regarding the deficiencies and opportunities for improvement in clinical documentation and encouraged adherence to key points. A template for the specific needs of the NICU was redesigned based on feedback received from all stakeholders on how to reduce the obstacles in adopting and retaining compliance with the new template. Results Compliance with the "key elements" of documentation improved dramatically after introducing a new template and feedback system. In the final cycle, the overall compliance was 81% (p<0.0001), well above our initial target of 60% compliance. Conclusion A unit that implements targeted audit-and-feedback measures relevant to the clinical team requirement can substantially and consistently improve documentation.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.