Staff Education on Vital Sign Assessment and Electronic Health Record Documentation for Acute and Critical Care Nurses and Patient Care Technicians

A staff educational quality improvement initiative aimed at enhancing the knowledge and accuracy of acute care nurses and patient care technicians (PCTs) in vital sign documentation was the focus of the doctoral project. Gaps in vital sign obtainment and electronic health record (EHR) documentation were identified through organizational serious safety event reviews, highlighting risks to patient safety and clinical decision-making. The project addressed the question of whether, in the inpatient hospital setting, a staff educational training program for acute and critical care nurses improves their knowledge of accurate vital sign documentation in the EHR. I analyzed pre- and posttest assessments and program evaluations using descriptive statistics and comparative review to measure participants’ knowledge gains, confidence, and potential documentation improvements. Findings demonstrated enhanced knowledge which could improve clinical judgment, consistency, and confidence in vital sign documentation, while identifying barriers, such as workload and equipment limitations. Major products included structured educational sessions; supporting materials; and recommendations for refresher training, expansion to all units, and EHR workflow optimization. The project reinforces evidence-based nursing practice; promotes safe and standardized care; and supports positive social change by ensuring equitable, high-quality care across patient populations.