Date of Award

Fall 12-2020

Degree Type


Degree Name

Doctor of Nursing Practice (DNP)


Leadership and Advanced Nursing Practice

Committee Chair

Dr. Cathy Hughes

Committee Chair School

Professional Nursing Practice

Committee Member 2

Dr. Marti Jordan

Committee Member 2 School

Leadership and Advanced Nursing Practice

Committee Member 3

Dr. Sheree Conley-Donaldson


This doctoral project’s purpose was geared toward strengthening quality healthcare outcomes documentation by constructing an updated policy and procedure manual specific to quality measures identified above, identifying attitudes and barriers to documenting, and assessing administration willingness to change. The project included a retrospective chart review of three populations and seven healthcare topics. Each diagnosis was researched utilizing specific ICD-10 (see Appendix A). A focus group/Pre-Implementation Questionnaire was administered to a panel of experts consisting of three nurse practitioners with one to nine years of experience employed at the FQHC. Afterward, a focus group was held to discuss barriers and attitudes to current EHR and the current manual. Lastly, eight administrators were given an updated manual and polled online questionnaires to assess the willingness to change and consideration for the adoption of updated executive summaries and policies and procedures. The focus group/administrators' total sample size was 11.

The project findings further strengthened the hypothesis of a formatted policy procedure manual will boost incentivized revenue. Guidelines outlined by the Health Resources and Services Administration were utilized for the development of the manual. The manual aligns with the theoretical evidence and may benefit other nurse practitioners and healthcare professionals for implementation.