That Was Then, This Is Now: Electronic Nursing Documentation

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1 That Was Then, This Is Now: Electronic Nursing Documentation KIRSTEN SKILLINGS, MA, RN, CCNS, CCRN AMY HILLEREN-LISTERUD, MA, RN, CNS, CBN, PCCN ST. CLOUD HOSPITAL

2 Purpose of Nursing Documentation Communication Continuity of care Evidence of quality of care Performance improvement, research, EBP Reimbursement Legal protection

3 The Good Ol Days Or Were They? Prior to EMRs Combination of electronic and paper Multiple documentation systems Where s my chart? Narratives frequently summarized data and interventions due to fragmented documentation systems SPEADO

4 Electronic Medical Records Supports real-time charting Easily retrieved from multiple locations by multiple users Provides structure and standardization Integrates devices (monitors, pumps, etc) Decision support, care prompts One-stop-shopping for information There s a flowsheet for that!

standardization Integrates devices (monitors, pumps, etc) Decision

5 Nursing Documentation in an EMR Desired outcomes: Standardize documentation throughout the hospital for ease of use and retrieval Ensure nursing documentation is complete, concise, accurate, non-duplicative, and done by exception Increase efficiency by eliminating duplicative documentation

Ensure nursing documentation is complete, concise, accurate,

6 Framework Charting by exception: a method of documenting findings, based on clearly defined standards of practice and predetermined criteria for assessment findings and interventions. Only significant findings or exceptions to the predefined standards are documented in detail. Charting by exception may guide both flowsheet and narrative documentation Recognized a legally sound when done well

Only significant findings or exceptions to the predefined standards are documented in detail.

7 Framework Multiple narrative formats were critiqued Susan Lampe s Focus Charting was selected

8 Focus Charting Process driven documentation format Supports outcomes based care Charting is done by exception Narrative documentation follows Data-Action- Response (DAR) format with a header Narrative documentation is concise

exception Narrative documentation follows Data-Action-

9 Documentation of Care Delivery Data and interventions reflecting care delivered will be primarily documented in flowsheets Flowsheet charting is documentation Narrative documentation will not routinely summarize data and interventions Follow charting by exception principles

charting is documentation Narrative documentation will not routinely

10 Required Note Types Event An occurrence or situation during the patient encounter that is significant enough to warrant narrative documentation in the medical record DAR format required Progress Evaluation of the patient s progress within the plan of care; includes the patient s status and/or response to treatment DAR format not required At least 1 event or progress note must be written for each patient within each shift, including 4 hour shifts

progress within the plan of care; includes the patient s status and/or response to treatment DAR format not

11 Transition Clearly define outcomes and expectations Have the right stakeholders at the table Identify documentation exemplars and change agents Monitoring tools are effective to a degree No substitute for 1:1 coaching and mentoring Set goals and timelines Include all stakeholders don t forget providers Nursing practice should drive EMR evolution, not the other way around

No substitute for 1:1 coaching and mentoring Set goals and timelines Include all stakeholders

12 Questions References: AHIMA e-him Work Group on Maintaining the Legal HER. (2005). Update: Maintaining a Legally Sound Health Record-Paper and Electronic. Journal of AHIMA, 76(10), 64A-L Austin, S. (2006). Ladies & gentlemen of the jury, I present... the nursing documentation. Nursing, 36(1), Barthold, M. (2009). Information technology. Standardizing electronic nursing documentation. Nursing Management, 40(5), Campos, N. (2009). The legalities of nursing documentation. Nursing Management, 40(8), Duclos-Miller, Patricia A. MS, RN, CAN, BC. (2007). Nursing Documentation: Reduce Your Risk of Liability. 2nd Edition. Gordon, M. (2007). Manual of Nursing Diagnosis (11 ed.). Sudbury, MA: Jones and Bartlett. Green, S., & Thomas, J. (2008). Interdisciplinary collaboration and the electronic medical record. Pediatric Nursing, 34(3), 225. TITLE: Clinical Documentation Page 6 of 6 G:\POLICIES- PROCEDURES\APPROVED\clinical_documentation.doc Kärkkäinen, O., Bondas, T., & Eriksson, K. (2005). Documentation of individualized patient care: a qualitative metasynthesis. Nursing Ethics, 12(2), Kerr, N. (2009). Is it time to change our perspectives on nursing documentation. MedSurg Nursing, 18(2), Lampe, S. (1997). Focus Charting, 7th ed. Minneapolis: Creative Health Care Management. Saranto, K., & Kinnunen, U. (2009). Evaluating nursing documentation -- research designs and methods: systematic review. Journal of Advanced Nursing, 65(3),

Nursing Documentation

Nursing Documentation Guideline: In ICFs/MR, information reflecting the nursing plan of care as well as other pertinent information should be documented in the individual s record in an accurate, timely, and legible manner.