Changes in Nursing Documentation Practices after Implementation of "Knowledge-Based Charting"

Thursday, 10 July 2008: 9:10 AM
Karen A. Grigsby, PhD, RN , College of Nursing, University of Nebraska Medical Center, Omaha, NE

Learning Objective 1: Identify two positive outcomes in nursing documentation practice after "Knowledge Based Charting" was implemented.

Learning Objective 2: Describe the impact of using an automated clinical documentation system on patient care.

Nurses are critical for monitoring, detecting, and preventing complications in hospitalized patients (Clarke & Aiken, 2003). The purposes of this descriptive study were to 1) describe documentation practices of nurses 6 & 12 months after implementation of Knowledge Based Charting (KBC) © and 2) identify the incidence of patient complications. A previous study established a baseline of documentation practices and patient complications. Methods. Data were obtained during site visits from 1) medical record review of 60 patients admitted with a diagnosis of Congestive Heart Failure (CHF), Pneumonia, or Stroke, 2) registered nurse interviews, and 3) demographic data. Data Analysis. Medical records were reviewed to determine 1) the completeness of the documentation; 2) which CPGs were selected for the care plan, and 3) the presence of ongoing documentation related to the selected CPGs. Data analysis of interviews used the constant comparative method (Glaser & Strauss, 1967), contextual data analysis (Belenky,, 1997), and dialectic processes (Guba & Lincoln, 1989). Data collected at 6 months and at 12 months after implementation of KBC were analyzed separately and then compared to results of the baseline study. Results. Themes identified from interviews included: 1) supporting clinical practice, 2) “it takes too much time”, and 3) integrating the new documentation system into how care is delivered. The review of medical records indicated that 1) an increased number of care plans included CPGs, 2) the majority of selected CPGs were physiological, and 3) there was a decrease in the number of patient complications. Conclusions. Findings suggest that nurses were increasing their utilization of CPGs in care plans and that use of CPGs may have alerted the nurses to intervene early or prevent patient complications and supported their use of critical thinking.