Learning Objective #1: Identify the advantages of the Omaha System for documentation

Learning Objective #2: Discuss challenges of documentation of care with frail elders

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The University of Delaware Nursing Center provides health promotion, disease screening and comprehensive consultation services to seniors and families with frail older adults. The Center staff selected the Omaha System to document the health promotion, education, screening and comprehensive assessment and intervention services provided. The characteristics of the Omaha System that led to its selection include: (1) ease of comprehension and use by multiple disciplines; (2) Ability to address physical, psychosocial and environmental needs of clients and their family members; (3) Standard outcomes measurement for client and family needs; (4) Ability to track outcomes; and (5) Inter-rater reliability.

All clients are evaluated using the 5-point knowledge, behavior and status scales. The staff met several challenges within the Omaha System. Documentation of comprehensive physical assessment required the addition of several items (e.g. breast health, nose & sinus system), a separation of subjective and objective findings, and a re-ordering of the items to a head-to-toe assessment. Multidisciplinary team members differed in their “traditional” medical vs. nursing system documentation needs. The combination of traditional geriatric screening and assessment measures within the Omaha System, however, met all health providers' and researchers' needs. Illustrative case studies will be included.