Standardised care plans for in hospital stroke care improve documentation of health care assessments

Aims and objectives To compare stroke unit staff members' documentation of care in line with evidence‐based guidelines pre‐ and postimplementation of a multi‐professional, evidence‐based standardised care plan for stroke care in the electronic health record. Background Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence‐based practice in hospital. Design Quantitative, comparative. Methods Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi‐professional evidence‐based standardised care plan with a quality standard for stroke care in the electronic health record. Results Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist‐documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. Conclusions An evidence‐based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. Relevance to clinical practice Use of a standardised care plan seems to have the potential to help staff adhere to evidence‐based patient care and, thereby, to increase patient safety.