RESUMEN
INTRODUCTION: In children requiring long-term mechanical ventilation (LTMV), insufficient admission charting can lead to adverse events. Our purpose in this study was to create and evaluate a structured documentation tool of home LTMV settings to improve communication, documentation, and patient safety. METHOD: This study used a pretest-posttest survey of pulmonary unit nurses' satisfaction with the tool and perceptions of patient safety, chart reviews of documentation compliance, and reports of education session attendance. Mann-Whitney U and Fisher exact tests, category analyses, and descriptive statistics were applied. RESULTS: Nurses' reports of positive communication of LTMV settings increased from 54.5% to 100% (p = .002), overall satisfaction with associated documentation increased (p < .001), and witnessed related adverse events decreased from 50% to 18.75%. Nurse compliance for education attendance and documentation was 97.4% and 97.3%, respectively. DISCUSSION: Structured admission charting of LTMV settings should be continued and yielded improvements in pulmonary unit nurses' perceptions of communication, patient safety, and documentation compliance.