Learning Objective #1: Describe changes in nurses’ documentation practices after introduction of Knowledge Based Charting (KBC), an integrated, automated clinical documentation system

Learning Objective #2: Describe how nurses’ use of KBC, an automated clinical documentation system, impacts delivery of care and the development of patient complications

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Nurses are critical for monitoring, detecting and preventing complications in hospitalized patients who are acutely ill and have co-morbidities (Clarke & Aiken, 2003; Institute of Medicine, 2003, 2004). Multiple demands, exacerbated by the current nurse shortage, decrease the nurses' ability to maintain adequate surveillance of patients. Organizations are implementing automated clinical documentation systems (ACDS) to ensure that care is safe and effective. Knowledge Based Charting© (KBC), an automated, integrated, clinical documentation system, includes Clinical Practice Guidelines (CPGs). Using CPGs alerts nurses to monitor patients for developing complications and to intervene early, thus decreasing patient mortality and morbidity. Effectiveness of ACDS that include CPGs has not been described. Purposes of this descriptive study are to describe: 1) documentation practices, including selection of Clinical Practice Guidelines, of nurses caring for patients admitted for Congestive Heart Failure (CHF), Stroke, or Pneumonia prior to and 6 months after implementation of KBC, and 2) the incidence of patient complications before and after KBC implementation. Setting/Population: Nurses working on four patient care units in the first hospital to implement KBC comprise the setting & population for this study. Sources of data include: medical records of 60 patients admitted with diagnoses of CHF, stroke, or pneumonia; organizational failure to rescue reports, demographic data; registered nurse interviews, and field notes. Procedure. Registered nurse interviews, demographic data forms, and medical record reviews were completed during 4 day on-site visits prior to and 6 months after KBC implementation. Data Analysis. Data analysis is in progress. Strategies being used include Ethnograph V, constant comparative method (Glaser & Strauss, 1967), contextual data analysis (Belenky, Clinchy, Goldberger, & Tarule, 1997), and dialectic processes (Guba & Lincoln, 1989). Implications. Using KBC, including the embedded CPGs, can assist nurses to maintain adequate surveillance of patients, decrease the development of complications, and deliver safe, effective care.