Hospital shrinks patient records into 1 document

Form provides snapshot of patient status

The staff at the Shepherd Center, an Atlanta specialty rehabilitation hospital, are doing less paperwork these days, thanks to a combined nursing assessment, clinical pathway, and interdisciplinary reporting document that eliminates up to a dozen assessment forms and progress notes and gives an instant snapshot of patient status.

The new documentation method gives Shepherd’s staff more time to spend treating patients, which is essential as managed care becomes more prevalent in Georgia, says Donna Court-Tillis, RN, MN, interdisciplinary pathway nurse, who spearheaded the effort.

"With strong managed care infiltration on the way, we no longer will have the resources to hire more staff," Court-Tillis says. "This is a way to give the staff more time to take care of patients."

It saves time for case mangers, too. Instead of having to compile separate documents from nursing and each therapy discipline for a report for an external case manager, the Shepherd case managers can simply copy a few pages from one easily accessible document and have an instant picture of patient status.

"Now, that information is easily accessible and the case managers no longer have to gather the information, they can spend their time making sure that we are making the best patient care decisions," Court-Tillis says.

Shepherd’s new form combines many pieces of documentation including therapy notes and treatment records (PT, OT, assistive technology, speech therapy, and therapeutic recreation), the nursing Kardex, skin progress records, blank progress note, nursing admission data, the patient care record, and clinical pathways.

The form includes a daily documentation sheet, primarily for nursing but with space for other disciplines to document changes and provide current updates on patient status, and a weekly documentation summary for all disciplines. The daily documentation is three pages, front and back.

The weekly documentation summary, which is charted by all disciplines, is divided into sections, including health status, activities of daily living, and mobility, instead of having separate sections for each discipline.

Clinical pathways are the core of the new documentation form and delineates patient care and goals for each phase of treatment.

When documenting, staff may check a box or answer yes/no questions in many cases, instead of writing out a narrative.

Charting by exception

The document uses charting by exception to save time for the therapists and nurses. The pathway spells out treatments the patients are expected to receive and goals the patients are expected to reach for each phase of treatment.

For example, the pathway may state that a patient will reach a certain outcome on transfers for a certain phase. If a patient reaches his or her goal on a specific functional item, the therapist does not list it on the chart. If the patient does not reach the goal, the therapist must explain why the goal has not been reached and what steps he or she will take to achieve the goal.

"We spent a lot of time looking at the layout and making it user-friendly," Court-Tillis says.

The new documentation process was initiated last September on the medical-surgical floor, where patients are admitted for conditions such as skin flap surgery, bladder augmentation, pneumonia, and exacerbations of multiple sclerosis, or with a brain injury listed at level 1 or 2 of the Rancho Los Amigos scale.

There are 13 pathways for med-surg patients and six for patients on the spinal cord unit. There are also generic pathways for patients who don’t fit into any specific category.

At present, Shepherd’s staff document primarily on paper. The hospital is working on a new information system, and the committee hopes to install computerized documentation in about two years. With an eye to the future, the forms were developed using as little narrative as possible, Court-Tillis says.

"After the initial shock wore off, the new system has worked very well," she says.

The staff has had to learn to let go of the old ways of doing things.

For instance, the nursing staff were reluctant to stop using the nursing Kardex tool, a working document kept for the convenience of the nursing staff, which does not become a part of the permanent record.

"We told the nurses we are not going to have them spend time writing down things that eventually go into the trash," Court-Tillis says.

The patients’ charts stay either at the nursing station or in the conference room. In the past, therapists were able to take their parts of the documentation to their offices to work on.

"We felt the only way it could work was to keep the documentation in one place so it was accessible to whoever needed it," Court-Tillis says.

Therapists also have had to begin charting a little earlier than they were used to doing. Some therapists were completing their therapy notes after the treatment team conference. Now, with the proactive model, they must have the documentation completed before the conference because the internal case manager uses the information to develop a patient summary statement.

Look to future

The new system encourages the nursing and therapy staff to look ahead and decide what the patients will need in the future.

For instance, if a patient will be living alone or in an independent living situation rather than living with family members, the staff will spend extra time on safety skills, problem solving, and mobility issues.

For example, if a patient is going from Shepherd to a nursing home, the staff should not spend a lot of time teaching complicated transfers that the patients never will use, Court-Tillis says.

"The system calls for the staff to look at what will suit the needs of the patients not only while they are here, but down the road," she explains. "We take discharge disposition and family resources into consideration. The staff is being asked to be tuned into the totality of patient care."

The new system is useful as a teaching tool for new staff because it shows in detail what they should be doing with patients each step of the way, Court-Tillis says.

The system began on the spinal cord unit in April. Next, administrators plan to set up a similar documentation system for patients with acquired brain injury.