Implementing a standardized nursing documentation note following positive Edinburgh postnatal depression scale screenings: a quality improvement project in a community hospital postpartum unit

Abstract

Postpartum depression is a common complication of childbirth that affects maternal well- being, infant development, and family functioning. Although routine screening using the Edinburgh Postnatal Depression Scale is widely implemented, gaps in documentation and communication following positive screening results may limit timely follow-up and continuity of care. At a community hospital postpartum unit in Montana, screening completion was consistently high; however, documentation of provider notification and follow-up actions after positive screens was fragmented across the electronic health record and difficult to verify. A quality improvement project was conducted to implement a standardized nursing documentation note to improve the consistency and visibility of documentation following positive screens. The intervention consisted of an electronic health record template embedded into routine nursing workflow, supported by staff education, tip sheets, and iterative Plan-Do-Study-Act cycles over a seven-week implementation period. Measures included education completion, use of the standardized documentation note following positive screens, and documentation of follow-up planning. Data were collected through retrospective weekly chart audits and analyzed using descriptive statistics. During the implementation period, 12 positive screening encounters were identified. The standardized documentation note was used in 8 of 12 encounters, and documentation of provider notification and follow-up actions was present in most cases, although sometimes recorded outside of the standardized note. Use of the standardized documentation note varied across weeks but was generally high when positive screens occurred. Implementation of a standardized documentation workflow was feasible within an inpatient postpartum setting and improved the organization and visibility of documentation related to follow-up care. Standardizing documentation processes may support safer discharge practices, improve continuity of care, and strengthen system-level responses to postpartum mental health needs.