Date of Award

Summer 2023

Project Type


College or School




Program or Major

Clinical Nurse Leader

Degree Name

Master of Science

First Advisor

Pamela Kallmerten


Background: Inaccurate and unreliable fluid balance documentation has been a long-standing issue in nursing. Best practice for “strict intake and output monitoring” is real-time accurate documentation.

Local Problem: Within a medical-surgical microsystem, it was identified that intake and output documentation (I/O) was not being completed thoroughly. A brief chart audit was conducted to identify gaps in documentation. In total, forty charts were audited, and two charts (5%) passed the audit. Common areas where documentation was incomplete included daily weights, output entered as “unmeasured occurrence”, IV fluid administration not totaled, or no intake recorded at all. We aimed to see a 30% increase in passed audits after intervention.

Methods: The A3 Problem Solving model for quality improvement was used as a framework for this project (A3 Problem, 2022). This model is based on the Plan, Do, Check, Act model. Chart audits were used during the plan phase to establish current state and a staff education on intake and output documentation was developed during the do phase.

Interventions: The intervention includes a pre-and-post intervention chart audit on patients ordered for “strict intake and output”. As well as a microsystem specific “intake and output” documentation and importance education poster.

Results: All elements of the chart audits saw at least a 30% increase in “pass” rates. This included intake, output, and fluid administration totals. It was also found that many fall-outs were patients that were ambulating to the bathroom independently.

Conclusion: This quality improvement project saw a positive impact on documentation after staff education and chart auditing. Further efforts should go into identifying a process for educating independent patient on the need to report their intake and output.