Running head: COLLABORATIVE INTAKE AND OUTPUT DOCUMENTATION
Collaborative Documentation for Accurate
Intake and Output in Hospitalized Patients
Elise Howard
The Pennsylvania State University
1
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
2
Abstract
A thorough review of the literature pertaining to the importance of intake and output
shows that there is a large gap in care that persists in the acute healthcare setting: incomplete and
inaccurate fluid balance documentation. A review of the relevant literature demonstrated a lack
of thorough research into interventions to rectify the issue of incomplete or inaccurate intake and
output documentation despite the research showing consistent results demonstrating the charting
inadequacies. This study aimed to highlight the differences between nursing estimation of intake
from meal trays and dietary assistants’ calculation when they take the trays out of the patients’
rooms. A pre- and post-intervention questionnaire was given to the nurses on a medical/surgical
trauma step-down unit to gather information about the perception of the accuracy and
effectiveness of fluid balance charts. Calculations showed that an average of 637.79 mL of fluids
were undocumented resulting in about three liters of inaccurately documented fluids over the
average length of stay at a hospital. Nursing questionnaires demonstrated that before the
implementation of dietary and nursing staff collaboration, there was little confidence in the
accuracy and effectiveness of fluid balance charts. After the intervention implementation and
being shown the calculated results, perceptions on accuracy and effectiveness rose, particularly
in respect to frequency of accurate intake charting. This method would utilize and already
existing tool of a bedside whiteboard to help connect the patient and the nursing staff as dietary
assistants could potentially write intake values on the board, thereby allowing nurses access to
assessments of intake that may have previously been missed.
Keywords: intake and output, documentation, fluid balance, collaboration, fluid intake-output
measures
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
3
Introduction
In a 2006 study by Kalisch concerning areas of frequently missed nursing care across the
profession, accurate documentation of patients’ intake and output was named as one of the
leading issues. It cites trays being taken away from patients’ room before nursing staff was able
to document what was consumed, lack of systematic recording methods regarding water pitcher
refills, as well as bathroom usage without nursing staff present. McGloin (2015) states that staff
shortages, lack of staff training, and limited time as barriers to accurately recording intake and
output. These missed documentations can have serious repercussions regarding patients’ health
such as overlooked signs and symptoms of kidney disorders, heart failure, urinary tract
infections, or perhaps even dehydration. Correct documentation of intake and output helps serve
physicians and nursing staff as an ongoing indicator of illness progression or recovery (Meiner,
2002). As stated by McGloin (2015), staffing shortages play a role in accurate documentation of
intake and output as the nursing staff cannot always be in the room before meal trays are taken
out of the room. Therefore, this research will attempt to answer the PICO question: is the
collaborative documentation of I&Os between nursing staff and dietary staff effective in
accurately depicting and maintaining patients’ hydrations statuses?
Many orders and prescriptions written by physicians are dependent on an accurate
account of fluid balance. These order and medications may be acted upon based on faulty
information in intake and output charting which may lead to negative patient outcomes like those
mentioned above. Therefore, it is critical that in any hospital setting documentation of patients’
intake and output of fluids be accurately portrayed. After speaking to the staff on the third floor,
South Addition, it was quickly determined that this is a perceived issue among the nursing staff
and in order to obtain better patient outcomes, it should be rectified.
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
4
Orders by physicians for cardiac and renal patients often include strict observance of
patients’ intake and output of fluids as well as daily weights to monitor fluid balance. Some
researchers are asserting that accurate documentation of intake in output is time and resource
intensive and that daily weights should be the sole order as it is less straining on resources (Wise,
Mersch, Racioppi, Crosier, & Thompson, 2000). However, there are additional aims to document
intake and output in patients on the 3rd floor South Addition. Not only is this a medical-surgical
floor, it also functions as a step-down unit associated closely with trauma, therefore, many of the
patients seen there are postoperative. This leads to the need of surveillance of fluid balance in
postoperative patients to determine the presence specifically of urinary retention, as it is
commonly seen after surgery as a complication of anesthesia intraoperatively as well as the
opioid analgesics to control pain postoperatively (Holte, Sharrock, & Kehlet, 2002). Proper
documentation of fluid balance in important especially for patients at risk for urinary retention as
the staff must know when to begin the diagnostic procedures for urinary retention such as
bladder scanning or straight catheterization (Johansson et al., 2012).
Some research maintains that of all charting done by nursing staff, fluid balance charts
were the least accurate (Armstrong-Esther, Browne, Armstrong-Esther, & Sander, 1996). While
updates in computer charting has made it easier to document, it is still difficult for nursing staff
to maintain accurate accounts of each of their patients. Some research suggests that increased
patient participation in recording intake and output may help to increase the accuracy in
documented amounts, however not all patients have the capacity to interact in such ways (Chung,
Chong, & French, 2002). In order to achieve accurate documentation, some researches
recommend the use of volume charts at bedside to produce more accurate representation of
intake and output for a given patient (Colley, 2015).
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
5
In a variation of this bedside chart, I intend to include dietary staff in recording patients’
intake after each meal. A card with fluid containers frequently used in the meals at the hospital
will be given to each of the dietary staff participating in this research. This will address the issue
that not all patients will be able to be reasonably educated on the volumes of each of the fluid
containers as described by Chung et al. (2002). This collaboration will utilize preexisting staff
resources and potentially overcome the perception of inadequate staffing to accomplish accurate
documentation of patients’ fluid balances.
Literature Review
Fluid balance charts have been a mainstay in acute care hospital settings and continue to
be so. The issue lies in their accuracy and healthcare providers’ perceived usefulness of the
charts as factual representations of patients’ fluid balance. In a 2006 study by Kalisch
concerning areas of frequently missed nursing care across the nursing profession, accurate
documentation of patients’ intake and output was named as one of the leading issues. It cites
trays being taken away from patients’ rooms before nursing staff was able to document what was
consumed, lack of systematic recording methods regarding water pitcher refills, as well as
bathroom usage without nursing staff present. McGloin (2015) states that staff shortages, lack of
staff training, and limited time as barriers to accurately recording intake and output. These
missed documentations can have serious repercussions regarding patients’ health such as
overlooked signs and symptoms of kidney disorders, heart failure, urinary tract infections, or
perhaps even dehydration. This review of the literature will highlight the findings of a
compilation of journal articles that deal with the importance of accurate fluid balance charting,
the barriers to their accuracy and full completion, and recommendations about fluid balance
charting improvements.
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
6
This research will attempt to answer if the collaborative documentation of intake and
output between nursing staff and dietary staff is effective in accurately depicting and maintaining
patients’ hydrations statuses. In a variation of bedside charts, I intend to include dietary staff in
recording patients’ intake after each meal. A card with fluid containers frequently used in the
meals at the hospital will be given to each of the dietary staff participating in this research. This
will address the issue that not all patients will be able to be reasonably educated on the volumes
of each of the fluid containers as described by Chung et al. (2002). This collaboration will
utilize pre-existing staff resources and potentially overcome the perception of inadequate staffing
to accomplish accurate documentation of patients’ fluid balances.
Review of the Literature
A thorough, computerized search utilizing Penn State Libraries’ compilation of multiple
databases, including CINAHL, The Nursing Resource Center, and ProQuest Nursing & Allied
Health Source was completed identify journal articles that have been published within the last
five years, 2010-2015. Unfortunately, not much has been published about this topic in this time
frame, therefore the time limit was expanded to include articles as far back as 1996 as some
fundamental articles describing the problem were published during this time, though most of the
articles were published within the past 10 years. The search terms utilized in the search included
“intake and output,” “fluid balance,” “fluid intake-output measures,” “documentation,”
“relationship based care,” and “collaboration.” the articles chosen and reviewed focused on the
importance of fluid balance charting, the barriers to their accuracy and full completion, and
recommendations about fluid balance charting improvements.
Importance of Accurate Fluid Balance Charts
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
7
Correct documentation of intake and output helps serve physicians and nursing staff as an
ongoing indicator of illness progression or recovery (Meiner, 2002). As previously cited,
McGloin (2015) states that staffing shortages play a role in accurate documentation of intake and
output (I&O) as the nursing staff cannot always be in the room before meal trays are taken out of
the room. Many orders and prescriptions written by physicians are dependent on an accurate
account of fluid balance. These orders and medications may be acted upon based on faulty
information in intake and output charting which may lead to negative patient outcomes like those
mentioned above. Therefore, it is critical that in any hospital setting documentation of patients’
intake and output of fluids be accurately portrayed.
Orders by physicians for cardiac and renal patients often include strict observance of
patients’ intake and output of fluids as well as daily weights to monitor fluid balance. Some
researchers are asserting that accurate documentation of intake and output is time and resource
intensive and that daily weights should be the sole order as it is less straining on resources (Wise,
Mersch, Racioppi, Crosier, & Thompson, 2000). However, there are additional aims to
document intake and output in patients on the 3rd floor South Addition on which I am conducting
my research. Not only is this a medical-surgical floor, it also functions as a step-down unit
associated closely with trauma, therefore, many of the patients seen there are postoperative. This
leads to the need of surveillance of fluid balance in postoperative patients to determine the
presence specifically of urinary retention, as it is commonly seen after surgery as a complication
of anesthesia intraoperatively as well as the opioid analgesics to control pain postoperatively
(Holte, Sharrock, & Kehlet, 2002).
Proper documentation of fluid balance is important especially for patients at risk for
urinary retention as the staff must know when to begin the diagnostic procedures for urinary
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
8
retention such as bladder scanning or straight catheterization (Johansson et al., 2012). Along
with the factors of anesthesia and opioid analgesics, there are many other factors that increase the
risk of the development of postoperative urinary retention (POUR). These include age, gender,
type of surgery, comorbidities, drugs (in addition to those mentioned above), and the duration of
surgery. Knowing that there are many factors that increase the chance of patients’ developing
POUR, it may increase the awareness of the importance of accurately documenting fluid balance
(Baldini, Bagry, Aprikian, & Carli, 2009).
Scales and Pilsworth (2008) cite that there are numerous indications for fluid balance
monitoring, including: intravenous infusions, subcutaneous infusions (hypodermoclysis), enteral
feeding, nasogastric tubes for aspiration or drainage, urinary catheterization, vomiting, diarrhea,
wound and chest drains, and medical conditions that affect fluid balance, for example heart
failure, renal failure, malnutrition, or sepsis.
Finally, there may be legal repercussions due to inaccurate fluid balance charting and
documentation. In a brief case study, Meiner (2002) illustrates that absence of charting or
inaccurate documentation of fluid balance may lead to missed care such as fluid and electrolyte
replenishment that could in turn lead to organ dysfunction like renal failure or cardiovascular
disease. These missed documentations could be viewed legally as negligence should untoward
patient outcomes result from them.
Barriers to Fluid Balance Chart Accuracy
Some research maintains that of all charting done by nursing staff, fluid balance charts
were the least accurate (Armstrong-Esther, Browne, Armstrong-Esther, & Sander, 1996). While
updates in computer charting has made it easier to document, it is still difficult for nursing staff
to maintain accurate accounts of each of their patients.
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
9
A qualitative study conducted by Kalisch (2006) showed that there are many missed
aspects of nursing care including accurate documentation of patient intake and output. The
article cited many barriers to quality charting in this area: too few staff, too much time required
for this intervention, poor use of existing staff resources, “it’s not my job” syndrome, ineffective
delegation, habit, and denial that there is an issue to being with (Kalisch, 2006).
Of note, there seems to be prevailing skepticism in terms of the accuracy of the fluid
balance charts which may explain why these documentations are often incomplete or inaccurate.
In a 2002 study that investigated the perceptions of the efficiency of fluid balance charting,
Chung, Chong, and French found that about 45% of nurses and nearly 80% of doctors regard
these charts as inaccurate. After an audit of medical charts (n = 120) totaling 649 days’ worth of
fluid balance charts it was found that 132 record days were incomplete and 92 daily fluid
calculations were inaccurate. This indicates that around 32% of the 24 hour fluid balance charts
are useless in determining a patient’s actual fluid balance (Chung, Chong, & French, 2002).
Many nurses know that documentation of output is much more difficult when the patient
is incontinent. This barrier is hard to hurdle without use of briefs for weighing after the patient
has been incontinent to measure with the formula of: 1 L = 1 kg (despite physiologic or
pathophysiologic changes in urine concentration). Such techniques are commonly seen on
pediatric floors, though rarely seen on adult floors. Additionally, briefs has been known to
increase the incidence of skin breakdown especially when soiled for a length of time. In an adult
population, perhaps moisture pads could be used as an alternative and measured to account for
incontinent urinary output (Galen, 2015).
Another barrier stated in an article by Chung, Chong, and French (2002) is that some
patients do not have the capacity or are not reasonably educated enough on the topic to
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
10
accurately describe what they have consumed and therefore, closer attention must be paid to
recording intake and output based on reliable observers.
Recommendations
Some research suggests that increased patient participation in recording intake and output
may help to increase the accuracy in documented amounts, however not all patients have the
capacity to interact in such ways (Chung, Chong, & French, 2002). In order to achieve accurate
documentation, some researchers recommend the use of volume charts at bedside to produce
more accurate representation of intake and output for a given patient (Colley, 2015).
Scales and Pilsworth (2008) recommend that patients be continuously screened for the
need of intensive monitoring of fluid balance which would hopefully decrease the amount of
time spent charting on intake and output on a patient that does not necessarily need it. They also
recommend that there be standard, graduated equipment for measuring fluid intake and output as
well as a reference chart for staff to use to ensure accuracy. Auditing of fluid balance charts is
also recommended to ensure that high quality recording is performed and maintained (Scales &
Pilsworth, 2008).
An article by Reid, Robb, Stone, Bowen, Baker, Irving, & Waller (2004) demonstrates
that only 11 of 20 nurses received formal training and education about fluid balance and its
importance in acute care settings while only 2 of 22 nursing aides had been trained. They state
that in order for intake and output to be more accurate and reliable, proper education of staff
must be obtained. They also recommend using signs at the bedside to denote that a particular
patient has been ordered intake and output monitoring for increased awareness. An increase in
patient participation (of patients who have the learning capacity) may also increase the accuracy
of these records. Wakeling (2011) reiterates that increasing staff knowledge and utilizing
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
11
alternative methods for patients to self-hydrate more independently will help to make these fluid
balance charts a more reliable source of information (Wakeling, 2011).
Another recommendation from Galen (2015) states that utilizing the practice often found
in pediatrics units of weighing moisture absorbent pads typically found under patients while in
bed or sitting in a chair. Additionally, adult briefs are sometimes used and can also be weighed
as a way to measure the amount of urinary incontinence in order to estimate more accurately the
output for the patient.
Of note, a randomized controlled trial by Bekhof, van Asperen, and Brand (2013) showed
that there was no significant difference in length of hospitalization in relation to the keeping of
fluid balance charts (p = 0.06) of neonates with moderate disease severity. The authors state that
fluid balance charts are often imprecise and consequently are an undependable source. While
this study does not address the population of interest, it is important in demonstrating just how
incomplete or inaccurate the intake and output charts are. Granted, more research needs to be
completed to ensure generalizability. However, it should be noted that neonates are closely
monitored during feedings and if inaccuracies can be found on this patient population, there is a
greater possibility that less supervised adult patients will have more inaccuracies.
Lastly, the use of an evidence-based practice of a fluid balance measurement policy has
been shown to increase accuracy in intake and output charts. Alexander and Allen (2011)
showed increased compliance in fluid measurement documentation after the implementation of a
policy that would populate an order set based on the initial physician order requiring monitoring
of intake and output (Alexander & Allen, 2011).
Interprofessional Collaboration
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
12
This intervention aims to utilize hospital staff to increase patient outcomes which entails
interprofessional collaboration between nursing staff and dietary staff. In a study conducted by
Zwarenstein and Reeves (2006), collaboration between professions will allow one profession to
report to the other regarding patient care and condition, especially aspects that may go unnoticed
under other conditions without collaboration. The collaborative intervention plan clearly
addresses this gap in care, allowing those who deal with patient food trays to accurately report
off on the intake to nursing staff.
Limitations
While it is known that many hospitals utilize a daily intake and output record for
numerous patients, there is limited research on whether or not these charts are reliable. Recently
some studies aimed to determine if there were alternative methods of observing fluid balance to
replace intake and output charts, namely daily weights. A study by Schneider, Baldwin, Freitag,
Glassford, and Bellomo (2012) showed that there was only a very weak correlation between
body weight and fluid balance (r = 0.34, P < 0.001). This shows that while daily weights are a
useful adjunct tool, fluid balance charting cannot simply be replaced. This study and others like
it looking at alternative fluid balance measures are undertaken because many view the
documentation of intake and output as staff-intensive and time-consuming (Schneider, et al.,
2012).
With that being stated, the reliability and utility of the fluid balance chart as a tool in
acute care settings need to be investigated. A 2000 study by Wise et al., show that the reliability
of fluid balance charting as they are currently completed fail to achieve high reliability which
may be due to failure to record voids or consumption of fluids at various times throughout the
day. It showed only moderate correlation between fluid balance and daily weight (r = 0.33, P =
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
13
0.004). A similar study by Eastwood (2006) demonstrates that there is poor reliability of fluid
balance charting in relation to weight gain, stating that the accuracy of the chart is often in
question. These results demonstrate the need for increased attention paid to the accuracy of
intake and output charting.
Action Plan
The plan of action that was implemented to answer PICO question if the collaborative
documentation of I&Os between nursing staff and dietary staff is effective in accurately
depicting and maintaining patients’ hydrations statuses. The gap that exists in the documentation
of intake and output was researched by involving the stakeholders of such a gap in care: nursing
staff, nursing administration, medical staff, and the patients themselves. It was initiated after
speaking with the nurse manager on the 3rd floor (south addition), Brian Cosner, and nursing
staff on the floor about issues that were prevalent on the floor which included undocumented or
inaccurately documented intake from meal trays. Also, there are professional nursing councils
that acknowledge the issue, but have yet to implement a potential solution. This study will
hopefully supplement the current research currently being done on the issue at the hospital and
potentially provide a resolution of the problem.
Methods
The scope of the project was included patients that are admitted to the trauma step-down
unit (3SAE/W) who have orders for intake and output. While this is an adult trauma step-down
unit, it acts as a medical/surgical overflow floor, therefore a variety of patients with a myriad of
acuities of illnesses. The patients seen in any hospital setting has the potential to be ordered close
observation of intake and output, therefore this study can be applied to many other acute care
areas. There are many individuals who worked as a team with this study to gain permission to
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
14
implement the intervention on the floor and to help work with the dietary assistants, all of whom
are listed in Table 1, below. All participants were given a brief introduction to the study detailing
what the study aimed to achieve and how it would be completed. This introduction can be found
in Appendix B.
Name
Phone
Unit
Shift
Victoria Durf
(717) 531-7338
3SAE/W
Days
Alicia Spencer
(717) 531-7338
3SAE/W
Days
Ashley Zipp
(717) 531-7338
3SAE/W
Rotating/Days
Brian Conser
(717) 531-0003
3SAE/W
Days
Lisa Black
(717) 531-7338
3SAE/W
Days
Anthony Bughi
(717) 531-7338
Dietary
Days
Table 1: Team member of the study
Nursing Perception Questionnaires. A Likert scale-style pre-intervention questionnaire
was developed by the principal researcher and was distributed to nursing staff employees caring
for the patients who were order intake and output observation inquiring their overall perceptions
about the accuracy and dependability of the fluid balance charting as it was before the
implementation of the above intervention. A Likert scale post-intervention questionnaire
utilizing the same questions as the pre-intervention questionnaire was given after the intervention
has been implemented to get a sense of how the nursing staff perceived the efficacy of the
intervention. Both pre- and post-intervention questionnaires can be found in Appendix B.
Comparison of Fluid Balances. Those who provide the patients with food (known as
dietary assistants at Hershey Medical Center) document and gave to the principal researcher,
Elise Howard, the total volume (in mL) intake from each meal tray of the selected patient as they
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
15
are also the staff that remove the trays as well. The dietary assistants were provided with a card
that details fluid containers commonly found on meal trays and their corresponding volumes in
milliliters (mL) as a reference guide and education point. A chart review was then completed,
specifically targeting the “I/O IVIEW” portion to compare the values that the nursing staff
documented as what they perceived to be the patients’ intake. The goal was to determine if
interprofessional collaboration between dietary staff and nursing staff is efficient in increasing
the accuracy of fluid balance charting.
Results
The nursing staff for the three data collection days were given pre- and postimplementation questionnaires on their perception of fluid balance charts before the intervention
was implemented and after seeing the results (missed mL of fluids per patient) for the day after
the intervention was implemented. A total of 11 nurses participated in the study questionnaires.
Before and after the implementation, all 11 nurses stated that they rely heavily on fluid balance
charts to make clinical decisions for their patients also citing that fluid balance charts are very
important in the proper care of patients. All 11 of the nurses who participated checked off that
doctors almost always, if not always, look at fluid balance charts when making clinical decisions
for their patients.
In the “Pre-Intervention Questionnaire however, 9 nurses checked that the accuracy of
fluid balance charts as they are currently completed are mostly not accurate or were neutral on
their perception on the accuracy of fluid balance charts. All 11 nurses checked the “Neutral” box
or lower when asked about how often intake was recorded; 1 nurse checked “”Intake is Never
Recorded,” 8 nurses checked “Intake is Mostly Not Recorded,” and 2 nurses checked that they
were “Neutral” about the topic of intake recording. When asked about the effectiveness of the
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
16
fluid balance charts as they are completed now, 7 nurses checked that they are “Mostly not
Effective” and 4 nurses checked that they are “Not Effective at All.”
In the “Post-Intervention Questionnaire,” the nurses were shown the average milliliters
that were missed on the intake and output charts for the patients and were asked to answer the
same questions from the “Pre-Intervention Questionnaire” as if intake were recorded via nursing
and dietary collaboration. The results showed that all 11 nurses believed that intake would be
“Mostly Recorded” (n=8) or “Always Recorded” (n=3). The perception of accuracy of the fluid
balance charts also increased with a majority (n=9) checking that fluid balance charts would be
“Mostly Accurate” and two nurses checking that they would be “Very Accurate.” There was also
an increase in the nursing confidence in their effectiveness in lineation with the accuracy of the
fluid balance charts with
The second portion of the study involved comparing the dietary calculation to the charted
nursing staff estimation. A total of 22 patients were eligible for the study and of that number,
data from 18 of the charts was used as four patients were discharged home on the day of data
collection and only partial data was collected on them.
After comparing the dietary calculation to the nursing estimation in the charts for day 1
of data collection, it was determined that the average difference between the two results for the
12-hour shift was 696.25 mL for the four patients that were observed. The total differences
between the nursing estimation and the dietary calculation can be found in Figure 1a. Day 2
collection results showed that there was an average difference of 451.11 mL between the nursing
estimation and the dietary calculation for the 9 patients included. Total differences between the
nursing estimation and the dietary calculation can be found in Figure 1b. Day 3 of data collection
included 5 patients and calculations showed an average difference of 766 mL incorrectly or
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
17
uncharted fluids. Total differences between the nursing estimation and the dietary calculation can
be found in Figure 1c.
Figure 1a: Nursing estimation of intake per tray versus dietary calculation on
day 1 of data collection.
Figure 1b: Nursing estimation of intake per tray versus dietary calculation
on day 2 of data collection.
Figure 1c: Nursing estimation of intake per tray versus dietary calculation
on day 3 of data collection.
After calculating the average differences of missed or inaccurately charted fluid amounts
for each of the data collection days, results showed that the average difference in mL from all 18
patients was 637.79 mL. This data implies that over a typical length of stay at a hospital, about
4.8 days (Centers for Disease Control and Prevention, 2010), around three liters of fluids can go
undocumented.
Limitations
Unfortunately, of the three days of data collection, only one day the primary researcher
was able to utilize the dietary assistant. The first day, the dietary assistants did not distribute or
collect patient trays leaving it to the principal researcher to act in lieu of the dietary assistant. The
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
18
second day of data collection applied the willing participation of the dietary assistant, Anthony
Bughi. On the third day of data collection, the dietary assistant was approached about
participation in the study, in which she stated it was out of her scope to participate. This may
have skewed the results in a positive way as the researcher is previously well educated about the
enhanced need for very close observation of patient intake and output.
While each day of data collection did not proceed as expected, they provided crucial
information about potential limitations as barriers that may face implementation of this type of
intervention. Not all days will have a dietary assistant to collect the tray which could lead to
another potential gap in care on these days. The tray collection would be left up to the nursing
assistants and therefore the documentation would also have to fall to them as well. Another
limitation that may arise with piloting this intervention is the unwillingness of dietary assistants
to participate. The literature states that a “not-my-job” type of attitude may present a barrier to
proper implementation and this was seen in this study as well. The dietary assistant stated that
the calculation of intake and output is part of the nursing assistants’ job, not hers.
Discussion
There are many repercussions with missing an average of 637.79 mL per 12-hour shift in
a fluid balance chart. Physicians often order continuous fluids for patients that are dehydrated or
are at risk for dehydration. However, patients may also have comorbidities that may make
unnecessarily running fluids dangerous such as heart failure or renal diseases. Intake and output
is a necessary part of the nursing assessment and there is clearly a gap in care for patients when
nursing staff is unable to accurately account for fluids that they consume. This proposed and
piloted collaboration would take a step in closing the gap in this population’s care.
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
19
Another issue that presented itself in the results of the study was that of low nursing
perceptions of the accuracy of fluid balance charts. If there is little to no confidence in their
accuracy, the nursing staff may potentiate their incomplete perceive characteristic by not
documenting intake and output that they witness. It is a vicious cycle that can be corrected with
simple collaboration and communication.
Nurses are known to be constantly busy and assisting in patient care, which makes
interprofessional communication difficult, however, many healthcare institutions are creating
tools to help keep the patient connected with their health care providers. At the Penn State
Hershey Medical Center, there are patient information whiteboards bedside already in use for
every patient bed on the floor and are updated at least every change of shift. The information
includes the patient’s preferred name, who their physician is, the nurse for the shift, and what
diet they are currently on. With this tool already in place, it would be simple to equip the dietary
assistants with a dry erase marker to utilize along with the white boards. This would cut tackle
the overwhelming issue of trying to create multiple points of communication between every
nurse on the floor and the dietary assistant. In addition, more communication with the dietary
office administrators may have resulted in better, more cooperative participation of the dietary
assistants.
Not only would this help to better guide clinical decisions, it could potentially save the
hospital in expenses that they could incur from complications that may have been prevented if
accurate intake and output were documented in the fluid balance charts. Much time and effort is
spent on the prevention of falls, hospital associated pneumonia, and hospital acquired urinary
tract infections as these are major points of lost money for the hospitals. Continued research into
better utilization of staff and more accurate documentation of intake and output could potentially
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
20
save hospital institutions as they may help to identify and prevent complications of fluid
overload or dehydration in patients.
Summary
Overall, this study aimed to highlight the often overlooked gap in care: missed intake
from meal trays. The existing literature shows that little research has been done on the topic, only
citing that is may be a missed component of patient care. While there have been some studies
that looked into replacing the fluid balance charts altogether in favor of daily weights, no studies
have demonstrated success in revealing that fluid balance charts are no longer needed. Therefore,
it is necessary not to find alternative methods to replace them, but to adapt the way they are
charted to obtain the most accurate values.
The accurate values of intake and output in fluid balance charts help to guide physicians
and nursing staff to care and make the best clinical decisions for patients. With inaccuracies
found in these charts, clinical judgment is skewed and could possibly result in poor patient
outcomes.
The results of this study support that nursing perceptions of the accuracy and
effectiveness of fluid balance charting as it is currently completed are low. The comparison of
the nursing estimations to dietary calculations demonstrate that there is a dire need to address
this issue of inaccurate intake and output documentation. On average, over half of a liter of fluids
goes undocumented on a given 12-hour shift on the floor. This missed assessment demonstrates a
need for further research into the issue. While many issues arose throughout the course of this
study, small changes to implementation could potentially overcome the hurdles. Simple
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
adjustments in the utilization of pre-existing tools such as bedside whiteboards could help
facilitate smoother interprofessional collaboration.
21
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
22
References
Alexander, L., & Allen, D. (2011). Establishing an evidence-based inpatient medical oncology
fluid balance measurement policy. Clinical Journal of Oncology Nursing, 15(1), 23–25.
http://doi.org/10.1188/11.CJON.23-25
Armstrong-Esther, C. A., Browne, K. D., Armstrong-Esther, D. C., & Sander, L. (1996). The
institutionalized elderly: Dry to the bone! International Journal of Nursing Studies, 33(6),
619–628. http://doi.org/10.1016/S0020-7489(96)00023-5
Baldini, G., Bagry, H., Aprikian, A., & Carli, F. (2009). Postoperative urinary retention.
Anethesiology, 10(5), 1139–1157.
Bekhof, J., Van Asperen, Y., & Brand, P. L. P. (2013). Usefulness of the fluid balance: A
randomised controlled trial in neonates. Journal of Paediatrics and Child Health, 49, 486–
492. http://doi.org/10.1111/jpc.12214
Centers for Disease Control and Prevention (2010). Number, rate, and average length of stay for
discharges from short-stay hospitals, by age, region, and sex. Retrieved from
http://www.cdc.gov/nchs/data/nhds/1general/2010gen1_agesexalos.pdf
Chung, L. H., Chong, S., & French, P. (2002). The efficiency of fluid balance charting: An
evidence-based management project. Journal of Nursing Management, 10, 103–113.
http://doi.org/10.1046/j.0966-0429.2001.00296.x
Colley, W. (2015). Use of frequency volume charts and voiding diaries. Nursing Times, 111(5),
12–16.
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
23
Eastwood, G. M. (2006). Evaluating the reliability of recorded fluid balance to approximate body
weight change in patients undergoing cardiac surgery. Heart & Lung: The Journal of Acute
and Critical Care, 35(1), 27–33. http://doi.org/10.1016/j.hrtlng.2005.06.001
Galen, B. (2015). Underpad weight to estimate urine output in adult patients with urinary
incontinence. Journal of Geriatric Cardiology, 12(2), 189-190. doi:10.11909/j.issn.16715411.2015.02.016
Holte, K., Sharrock, N., & Kehlet, H. (2002). Pathophysiology and clinical implications of
perioperative fluid excess. British Journal of Anesthesia, 89(4), 622–632.
Kalisch, B. J. (2006). Missed nursing care: A qualitative study. Journal of Nursing Care Quality
Vol. 21, No. 4, Pp. 306-313, 21(4), 306–313.
McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. British Journal of
Nursing, 24(1), 14–19.
Meiner, S. E. (2002). Fluid balance documentation: A case study of daily weight and
intake/output omissions. Geriatric Nursing, 23(1), 46-47.
Reid, J., Robb, E., Stone, D., Bowen, P., Baker, R., Irving, S., & Waller, M. (2004). Improving
the monitoring and assessment of fluid balance. Nursing Times, 100(20), 36–39.
Scales, K., & Pilsworth, J. (2008). The importance of fluid balance in clinical practice. Nursing
Standard, 23(47), 50–57.
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
24
Schneider, A. G., Baldwin, I., Freitag, E., Glassford, N., & Bellomo, R. (2012). Estimation of
fluid status changes in critically ill patients: Fluid balance chart or electronic bed weight?
Journal of Critical Care, 27(6), 745.e7–745.e12. http://doi.org/10.1016/j.jcrc.2011.12.017
Wakeling, J. (2011). Improving the hydration of hospital patients. Nursing Times, 107(39), 21–
23.
Wise, L. C., Mersch, J., Racioppi, J., Crosier, J., & Thompson, C. (2000). Evaluating the
reliability and utility of cumulative intake and output. Journal of Nursing Care Quality,
14(3), 37–42.
Zwarenstein, M., & Reeves, S. (2006). Knowledge translation and interprofessional
collaboration: Where the rubber of evidence-based care hits the road of teamwork. Journal
of Continuing Education in the Health Professions, 26(1), 46–54.
http://doi.org/10.1002/chp.50
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
25
Appendix A
Thank you for your participation in this brief study. The aim of this study is two-fold:
1. To measure the perceptions of fluid balance charting (I&O) of the nursing staff.
2. To measure the effectiveness of collaboration between dietary staff and nursing staff on
I&O charting accuracy.
The first aim will be investigated via a pre- and post-intervention questionnaire. The second will
be done by asking dietary assistants that collect trays at the end of meals to record the fluid
intake of the patient and report them to me (Elise Howard S.N.). These values will then be
compared to those estimated by the nursing staff.
These results will only be used to study the effectiveness that this collaboration has on
the accuracy of intake and output charts. The results will be shared with the Second Degree
Accelerated Nursing 2015/16 cohort and associated professors. Names of participants can remain
anonymous if requested. Names will only indicate participation in this study. When the results of
the study are presented, values will not be associated with any particular individual.
Thank you!
Elise Howard, S.N.
B.S. Biobehavioral Health
College of Nursing
The Pennsylvania State University
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
26
Appendix B
Pre-Intervention Questionnaire
Instructions: Please rate your perception of the following areas on a scale of 1 to
5. For each category, the place a checkmark in the box that corresponds with how
you feel.
* Note that “FBC” stands for “fluid balance charts,” also known as “intake and output” documentation.
1
2
3
4
5
Not Important At All
Mostly Not Important
Neutral
Mostly Important
Very Important
Not At All
Mostly Do Not Help
Neutral
Mostly Help
All The Time
Not Effective At All
Mostly Not Effective
Neutral
Mostly Effective
Very Effective
Not Accurate At All
Mostly Not Accurate
Neutral
Mostly Accurate
Very Accurate
Doctors Never Look
Doctors Mostly Do Not
Look
Neutral
Doctors Mostly Look
Doctors Always Look
Output is Never
Recorded
Output is Mostly Not
Recorded
Neutral
Output is Mostly
Recorded
Output is Always
Recorded
Intake is Never
Recorded
Intake is Mostly Not
Recorded
Neutral
Intake is Mostly
Recorded
Intake is Always
Recorded
IMPORTANCE
OF FBCS
FBCS HELP ME
M AKE CLINICAL
DECISIONS
EFFECTIVENESS
OF FBCS
ACCURACY OF
FBCS
DOCTORS
LOOK AT FBCS
OUTPUT
RECORDED
INTAKE
RECORDED
COLLABORATION OF INTAKE AND OUTPUT DOCUMENTATION
27
Post-Intervention Questionnaire
Instructions: Please rate your perception of the following areas on a scale of 1 to
5. For each category, the place a checkmark in the box that corresponds with how
you feel.
* Note that “FBC” stands for “fluid balance charts,” also known as “intake and output” documentation.
1
2
3
4
5
Not Important At All
Mostly Not Important
Neutral
Mostly Important
Very Important
Not At All
Mostly Do Not Help
Neutral
Mostly Help
All The Time
Not Effective At All
Mostly Not Effective
Neutral
Mostly Effective
Very Effective
Not Accurate At All
Mostly Not Accurate
Neutral
Mostly Accurate
Very Accurate
Doctors Never Look
Doctors Mostly Do Not
Look
Neutral
Doctors Mostly Look
Doctors Always Look
Output is Never
Recorded
Output is Mostly Not
Recorded
Neutral
Output is Mostly
Recorded
Output is Always
Recorded
Intake is Never
Recorded
Intake is Mostly Not
Recorded
Neutral
Intake is Mostly
Recorded
Intake is Always
Recorded
IMPORTANCE
OF FBCS
FBCS HELP ME
M AKE CLINICAL
DECISIONS
EFFECTIVENESS
OF FBCS
ACCURACY OF
FBCS
DOCTORS
LOOK AT FBCS
OUTPUT
RECORDED
INTAKE
RECORDED