Among the challenges facing nurses in acute care facilities are duplicate documentation, complex rules for coordinating care, and pressure to accelerate patient discharge. Christiana Care, a two-hospital, 900-bed health system in Delaware, redesigned its nursing admissions process to address these issues and provide a centralized source of assessment information. An interdisciplinary team redesigned the assessment process to leverage the clinical documentation, decision support, and workflow tools of Christiana Care's evolving electronic health record. Nurses use a wireless device at the patient's bedside to enter admission information. A series of decision-support rules evaluate the information and send electronic referrals to appropriate ancillary departments. Departments electronically document interventions that can be tracked by nursing, closing the loop.A dedicated rollout coordinator and system-generated audit reports were critical to early identification and resolution of several implementation problems. The new process has not only simplified the work of nursing but led to more appropriate referrals to the ancillary departments. More than 25 percent of the patients have information imported from a previous encounter, eliminating duplicate documentation and improving patient satisfaction. Admission information also is being used to monitor and support a variety of quality efforts, including core measures.
[1]
Shannon Cowden,et al.
A Process for Consolidation of Redundant Documentation Forms
,
2004,
Computers, informatics, nursing : CIN.
[2]
C. Langowski.
The Times They Are A Changing: Effects of Online Nursing Documentation Systems
,
2005,
Quality management in health care.
[3]
Jackie Laughlin,et al.
Boost regulatory compliance with electronic nursing documentation.
,
2003,
Nursing management.
[4]
C. Ruland,et al.
Developing a module for nursing documentation integrated in the electronic patient record.
,
2001,
Journal of clinical nursing.