No more double documentation
At OSF Saint Francis Medical Center in Peoria, IL, the nursing staff was aghast when the nursing kardex was eliminated. But now they love it, says Janis Noone, RN, MSN, clinical practice specialist.
That’s because they now use a new documentation system based on an interdisciplinary plan of care for all patients. The hospital had been using CareMaps but didn’t have anything standardized for patients who didn’t fit one of those conditions. Now, generic pathways based on the CareMaps mean every patient has a standardized form. Physician orders are transcribed directly onto the plan of care, which eliminates the need to double-document, Noone says.
The interdisciplinary forms have an established place for every piece of information needed from the critical care unit to the mother/baby unit to the psych ward. The new system encourages the use of charting by exception and has cut documentation time in half. It has also defined standards and cut down on incomplete, inconsistent patient monitoring. "We also have captured information flow from a variety of pre-admission settings so that patients are not asked the same questions several times upon admission," Noone says. "The patient benefits the most, as more time is now available for direct care activities. They are not asked the same information repeatedly during admission. Discharge information is provided to them and to the care team members assuming their care after the inpatient stay."
To read more about this documentation system and other everyday innovations, visit the Best Practice Network’s Web site at www.best4health.org. The Best Practice Network, a new organization devoted to promoting information sharing in health care by nurses, physicians, and other health care professionals, offers creative solutions to problems large and small.
For more information, send an e-mail to firstname.lastname@example.org or call (800) 899-2226.
For more information, contact Susan Swier, RN, BS, CPHQ, Quality Improvement Coordinator, Sarasota Memorial Healthcare System, 1700 Tamiami Trail, Sarasota, FL 34239. Telephone: (941) 917-2447.