Canberra Health Services policy recommends Introduction, Subjective, Objective, Analysis, Plan (ISOAP) format for all clinical documentation. In 2021 there was no standard format in the documentation in written nursing clinical notes in the Neonatal Intensive and Special Care (NICU/SCN). Our team conducted a pre- implementation audit that showed only 2% used the ISOAP format.

To increase the use of ISOAP documentation format from 2% to 50% (Jan 22) and 90% (April 22) and 90% (May 23) post DHR rollout.

This study was designed on the Institute of Health Care Improvement Model, utilising PDSA cycles (CHS QI No 2342). The project included: development of templates, posters, lanyards, and examples of ISOAP documentation for use across NICU/SCN. Staff Education via in-service, email, and one-to-one education. Clinical Audits were undertaken post implementation.

Audits of clinical reports showed an increase from 2% (pre) to 78% (3 months post). These results were supported by the CHS Clinical Audit completed in March 2022, reporting 100% of were completed in ISOAP format. A post DHR audit reported 65% written in ISOAP and 20% in a Systemic format. We are currently updating templates to increase uptake of ISOAP format in DHR.

Implementation of ISOAP has assisted in standardised nursing documentation across NICU/SCN. ISOAP format provides nurses a format to document; neonatal observations and assessments, changes in condition, and daily care plan, while facilitating clear documentation of family needs and participation in their baby’s care. 

First project to develop ISOAP guidelines that meet the clinical documentation requirements for neonates admitted to a NICU/SCN.

 

Margaret M Broom1,2, Laura Briguglio1, Juby Joseph1, Heather Heslop1, Lori Grjl1, Clare O'Brien1

 
 

1.     Centenary Hospital for Women and Children, Department of Neonatology, Garran, ACT, 2606

2.     SYNERGY: Nursing and Midwifery Research Centre, UC and ACT Health