Paper
Saturday, November 3, 2007
18
Do Nurses' Documentation Practices Change after Implementation of an Automated Clinical Documentation System?
Karen A. Grigsby, PhD, RN and Peggy Tidikis-Menck, PhD, RN. College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| Learning Objective #1: identify changes in documentation practices after implementation of Knowledge Based Charting, an automated clinical documentation system. |
| Learning Objective #2: describe the benefits of using Clinical Practice Guidelines as part of the care planning and documentation system. |
Clinical practice guidelines (CPGs) support nurses’ clinical reasoning and improve patient outcomes; CPG use is limited by both acceptance and accessibility. Purpose. This study describes changes in nurses’ documentation practices and patient outcomes in one healthcare organization six months after an automated clinical documentation system (Knowledge Based Charting or KBC ©) was implemented. A previous study established a baseline to identify changes. Methods. Data were obtained during site visits from 1) review of medical records for a random sample of 60 patients admitted with a diagnosis of Congestive Heart Failure, Pneumonia or Stroke, 2) organizational Failure to Rescue reports, 3) demographic forms, and 4) nurse interviews. Data analysis. Medical records were reviewed to determine 1) which CPGs were included on the care plan, and 2) the presence or absence of ongoing documentation related to the selected CPGs. Organizational Failure to Rescue reports were analyzed to determine if nursing actions were beneficial or harmful. Data analysis of interviews used the constant comparative method (Glaser & Strauss, 1967), contextual data analysis (Belenky et al, 1997), and dialectic processes (Guba & Lincoln, 1989). Data collected 6 months after implementation of KBC were analyzed and then compared to results of the baseline study. Results. One or more CPGs was included in 82% of the medical records. When a CPG was not selected, 25% of the patients developed a complication. When CPGs were selected, only 10% of the patients developed complications. One major theme identified was a lack of time to document. Conclusions. Findings suggest that 1) patient complications decreased when CPG’s were included as part of the plan of care, 2) use of CPGs improved after KBC was implemented and 3) time to document is limited. Implications. Using care plans that include CPGs may alert the nurse to intervene early to prevent patient complications.