Implementation of Online Documentation in Labor & Delivery, Benefits and Challenges

2.50
Hdl Handle:
http://hdl.handle.net/10755/148957
Type:
Presentation
Title:
Implementation of Online Documentation in Labor & Delivery, Benefits and Challenges
Abstract:
Implementation of Online Documentation in Labor & Delivery, Benefits and Challenges
Conference Sponsor:Sigma Theta Tau International
Conference Year:2005
Author:Heale, Patricia A., MSN, RNC
P.I. Institution Name:Newton Wellesley Hospital
Title:Clinical Nurse Specialist
Co-Authors:Virginia Prout, MSN, RN
The Computerized Patient Record (CPR) is fast becoming a high-tech addition to many Labor & Delivery units. Interfacing with fetal monitoring technology the CPR has the capacity to provide surveillance of fetal heart rate tracings, archival on CD-ROM, a complete online documentation system including direct notation on the fetal heart rate tracings and an online documentation package that is configurable for all Maternal/Child Health areas. The institution purchased the QS product in 2001 and the surveillance option was implemented immediately. By the winter of 2003 it was clear that the system had been underutilized. A project plan was designed and a multidisciplinary team organized and then charged with implementation of the archival feature and the QS online documentation system. In a time of strict resource management it was necessary to define the benefits as a rationale for the time to be invested. Benefits of CPR implementation included: improved documentation and compliance with clinical guidelines, increased nurse to patient contact, support decision analysis, identification of outcome measures resulting in MCH system improvement and the incorporation of patient education materials and clinical pathways into the CPR. These benefits became the team's goals but were not without associated challenges including allocation of both personnel and financial resources, orientation and ongoing support (24/7) for nursing staff during implementation of the new documentation model, consideration for staff stress during the change process and the challenge of providing high quality patient care throughout implementation of the practice change. Evaluation tools were developed and used throughout to determine the projects successes and challenges. Celebrations of successes and meeting the uncovered challenges became goals for the future.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleImplementation of Online Documentation in Labor & Delivery, Benefits and Challengesen_GB
dc.identifier.urihttp://hdl.handle.net/10755/148957-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Implementation of Online Documentation in Labor &amp; Delivery, Benefits and Challenges</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2005</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Heale, Patricia A., MSN, RNC</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Newton Wellesley Hospital</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Clinical Nurse Specialist</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">pheale@partners.org</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Virginia Prout, MSN, RN</td></tr><tr><td colspan="2" class="item-abstract">The Computerized Patient Record (CPR) is fast becoming a high-tech addition to many Labor &amp; Delivery units. Interfacing with fetal monitoring technology the CPR has the capacity to provide surveillance of fetal heart rate tracings, archival on CD-ROM, a complete online documentation system including direct notation on the fetal heart rate tracings and an online documentation package that is configurable for all Maternal/Child Health areas. The institution purchased the QS product in 2001 and the surveillance option was implemented immediately. By the winter of 2003 it was clear that the system had been underutilized. A project plan was designed and a multidisciplinary team organized and then charged with implementation of the archival feature and the QS online documentation system. In a time of strict resource management it was necessary to define the benefits as a rationale for the time to be invested. Benefits of CPR implementation included: improved documentation and compliance with clinical guidelines, increased nurse to patient contact, support decision analysis, identification of outcome measures resulting in MCH system improvement and the incorporation of patient education materials and clinical pathways into the CPR. These benefits became the team's goals but were not without associated challenges including allocation of both personnel and financial resources, orientation and ongoing support (24/7) for nursing staff during implementation of the new documentation model, consideration for staff stress during the change process and the challenge of providing high quality patient care throughout implementation of the practice change. Evaluation tools were developed and used throughout to determine the projects successes and challenges. Celebrations of successes and meeting the uncovered challenges became goals for the future.</td></tr></table>en_GB
dc.date.available2011-10-26T09:53:33Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T09:53:33Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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