| Learning Objective #1: Describe a documentation system with basic tools for demonstrating an interdisciplinary link to completion of patient outcomes | |||
| Learning Objective #2: Identify three changes that can be made in documentation to demonstrate a connection to the patient in terms of patient-desired outcomes |
Recent years have seen the use of an outcomes based delivery model become a very positive and popular approach to the provision of nursing care in an acute care environment. However, despite the simplicity of the concept, and the success that a focus on outcomes can bring, nurses continue to struggle with how to demonstrate, to "prove" that they have created a link with the patient in terms of outcomes and to document these efforts.
In a University health center setting, a primary outcomes-based model was implemented on the inpatient care delivery units. The previous documentation system was problem based, with the problem list initiated and maintained by nursing. Still in the manual mode of charting, and yet looking to prepare for computerization, nurses were struggling with the integration of "outcomes" to "problems". Further, chart audits found that there was limited/no evidence of interdisciplinary collaboration in patient care.
This session will describe the basic changes of a struggling documentation system, to one that reflects a solid connection to desired patient outcomes, and evidences the interdisciplinary planning that is part of a successful patient hospitalization. Three changes in chart forms resulted in a system that saves time, validates and provides evidence of the patient/health care provider connection, and increases nursing satisfaction while improving team communications.
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Sigma Theta Tau International