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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 9


Rachel Hernandez

Electronic Documentation

By Rachel Hernandez, BSN, RN, CPON
 

When you first heard the words “electronic documentation” what was your gut reaction? For some there was the feeling that paper charting is as antiquated as snail mail and hoop skirts, and there were some who cautiously anticipated the change, but perhaps couldn’t quite visualize how the entire process would help them deliver patient care. Electronic documentation is an ever growing part of patient care and Children’s Hospital Central California has moved forward with the Advanced Clinical Systems (ACS) project.

Electronic documentation is a vast puzzle that encompasses so many aspects of patient care that at times it is difficult to comprehend. Utilizing electronic documentation serves to unify the pieces to create an entire picture of patient care accessible to every person involved in ensuring care is done safely and meets regulatory requirements. Each one of us may be able to see our own piece of the puzzle but perhaps are unsure of how it connects to the next person’s piece (e.g., documentation of the plan of care).

Creating a standardization of language within electronic charting allows care providers to easily trend and compare patient status. During our training most of us learned many different terms often used to describe the same element. For example, if there were a patient whose lungs sounded like the crinkling of a Fritos bag with each breath, would the correct documentation be crackles or rales? Standardizing terms and definitions allows for direct comparison and trending. When all care partners are using a standardized language, with shared definitions, each assessment creates a clear picture of the condition of the patient.   

Standardization of care indicators allow for increased reporting. With a click of the mouse, data elements can be plucked from the medical record, sorted and categorized, thus allowing for more immediate and meaningful use of the information. Have you experienced the joy of searching through piles of charts, deciphering hieroglyphics, to search for elements required for a comprehensive chart audit? If you have never been exposed to this experience, it may be like looking for a needle in a haystack.

Efficient design of the electronic documentation leads the care provider to enter the elements required to demonstrate safe and competent care. Care providers do not need to rely on policy and procedure recollection alone to remember all of the elements required to be documented.

Electronic documentation allows for the transition from a somewhat unreliable, paper process to one that is dynamic and linked to all parts of the medical record, including physician orders and the nursing plan of care. Care providers get visual alerts from the computer reminding them to perform care activities such as giving a medication or providing a treatment. When completing documentation, the care provider is guided to document all elements that create a clear record of the care. Plans of care are the basis for providing holistic care to each patient and their family. Care plans define patient specific problems, establish measurable outcomes and outline interventions that are used to direct ongoing patient care. The nurse uses critical thinking to complete the nursing process of assessment, diagnosis, planning, implementation and evaluation.1

Electronic documentation incorporates the plan of care as the driving force behind the interventions. The relationship between the care plan, activities of care and documentation becomes dynamic. Interventions are provided at intervals related to the needs of the patient, and when outcomes are met, the problem is resolved in the electronic environment. New interventions can be added immediately to the patient’s plan of care and the process continues.

Karen Duncan, RCP, Sandra Edmiston, RN, Mark Fung, RN, Allessandra Rossi, RN and I make up the ACS build team and serve on the Nursing Informatics Council (NIC).

Leading the build team and chair of the Nursing Informatics Council is Shirleen Fowler, RN, Director. Janice Helmstetter, Nursing Administrative Specialist, provides administrative support in the role of recorder. The NIC functions as an internal user group for the organization involved in applying information technology (IT) to nursing practice and clinical process changes. Staff identified as super-users support clinical applications at the point of care and validation of competency for department staff, and provide input and feedback into ongoing clinical IT development impacting nursing practice and care.

 

In addition to the build team members listed above, the NIC members are:

Edward Blake, RN, Apollo

Tom P. Desch, RN, Pediatric Rehab

Allen Henning, RN, House Resources

Jo A. Lyons, RN, Patient Care Support

Rachel Meisner, RN, Explorer

Angelina Neal, Applications Consultant, ITS

Christine Netzley-Morales, RN, Perioperative Services

Sandra Valenti, RN, Discovery

Eleuterio (Jr) Watson, RCP, Respiratory Care Services

Leone Wiens, RN, Patient Care Education

 

NIC Ad Hoc Membership include:

Roberta Baranda, Director, Health Information Management

James Brusenback, RN, Manager, Emergency & Trauma Services Department

Bryan Carlson, Pharmacist, Safety-Compliance

Sherri A. Fox, RN, Utilization Review Nurse Coordinator, Case Management 

Diana Johnson, RN, Clinical QRM Coordinator, Clinical Risk Management

Beverly Hayden-Pugh, RN, Vice President/Chief Nursing Officer, Patient Care Division

Linda M. Okajima, Supervisor, Laboratory Administration

Robert Turner, Supervisor, Network Services

Donna Yoshida, Operations Manager Medical Imaging.

 

Careful development and proper use of documentation tools can create a clear picture of patient care through standardized language, amplify connectivity between care providers, increase the ability to report care indicators and support the nursing process. As we progress with the ACS project we will inevitably find opportunities for improvement. If you see any members of the ACS build team or the NIC, please say thanks and know that your input is always welcomed!

 

Reference

1Ackley & Ladwig, B.J & G.B. (2011). Nursing diagnosis handbook an evidence-based guide to planning care. St. Louis, Missouri: Mosby Elsevier.

 

 

In This Issue

A Recipe for Advanced Clinical Systems

Code of Ethics for Nurses

Champions… A Key to Success

Optimizing the Wound Healing Environment

Electronic Documentation

The Pace of Regulatory Change

Alphabet Soup in the Ambulatory Division

Shared Governance: PICU Skin Care Program

Striving for Excellence in Children's Asthma Care

Patient Satisfaction Comments