Designing and Implementing a Significant Findings Charting System in the Pediatric Emergency Department

2.50
Hdl Handle:
http://hdl.handle.net/10755/162796
Type:
Presentation
Title:
Designing and Implementing a Significant Findings Charting System in the Pediatric Emergency Department
Abstract:
Designing and Implementing a Significant Findings Charting System in the Pediatric Emergency Department
Conference Sponsor:Emergency Nurses Association
Conference Year:1997
Author:Barnardo, Lisa M., RN, PhD, CEN
Contact Address:, USA
Co-Authors:Marion Davis, RN; Linda Gray, RN; and Dorcas Howley, RN
Clinical Topic: The charting by exception (or significant findings charting [SFC]) system requires nurses to document only those pertinent clinical data that have changed from the previous assessment. This system decreases the time required for documentation and enhances the quality of the documented data. We designed the SFC system for our Emergency Department (ED), and conducted a trial testing of the system's use and conducted quality improvement on the system to ensure its proper usage.

Process of Implementation: The SFC system is composed of a documentation form and guidelines. We designed the Emergency Nursing Flow Sheet to document nursing care for non-trauma patients. Emergency nurses critiqued and tested the Flow Sheet with patient scenarios; revisions were made, and the Flow Sheet approved. We developed SFC system guidelines based on our Emergency Nursing Patient Care Standards to delineate the normal and abnormal criteria for each assessment parameter. The guidelines also outlined how and when the Flow Sheet is used, who documents on the Flow Sheet, and the frequency of documentation during patient care.

Outcomes: The entire process of developing, testing and approving the SFC system required approximately 6 months' time. Following a two week SFC system orientation for the emergency staff, the SFC system was implemented.

Recommendations for Clinical Practice: Our documentation became easier and quicker with the SFC system. Thorough patient assessments are completed, and changes in the patientÆs condition are defined clearly. There has been substantial decrease in documentation time and redundancy.

Our quality improvement audits are conducted quickly because of the simplicity of this system's charting. We are finding a completeness in our documentation that was lacking with our former narrative documentation system. The SFC system has been a successful venture in our ED. Emergency nurses should consider implementing a SFC system for their patient care. [Clinical Poster Presentation]
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleDesigning and Implementing a Significant Findings Charting System in the Pediatric Emergency Departmenten_GB
dc.identifier.urihttp://hdl.handle.net/10755/162796-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Designing and Implementing a Significant Findings Charting System in the Pediatric Emergency Department</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">1997</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Barnardo, Lisa M., RN, PhD, CEN</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">, USA</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">res@ena.org</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Marion Davis, RN; Linda Gray, RN; and Dorcas Howley, RN</td></tr><tr><td colspan="2" class="item-abstract">Clinical Topic: The charting by exception (or significant findings charting [SFC]) system requires nurses to document only those pertinent clinical data that have changed from the previous assessment. This system decreases the time required for documentation and enhances the quality of the documented data. We designed the SFC system for our Emergency Department (ED), and conducted a trial testing of the system's use and conducted quality improvement on the system to ensure its proper usage.<br/><br/>Process of Implementation: The SFC system is composed of a documentation form and guidelines. We designed the Emergency Nursing Flow Sheet to document nursing care for non-trauma patients. Emergency nurses critiqued and tested the Flow Sheet with patient scenarios; revisions were made, and the Flow Sheet approved. We developed SFC system guidelines based on our Emergency Nursing Patient Care Standards to delineate the normal and abnormal criteria for each assessment parameter. The guidelines also outlined how and when the Flow Sheet is used, who documents on the Flow Sheet, and the frequency of documentation during patient care.<br/><br/>Outcomes: The entire process of developing, testing and approving the SFC system required approximately 6 months' time. Following a two week SFC system orientation for the emergency staff, the SFC system was implemented.<br/><br/>Recommendations for Clinical Practice: Our documentation became easier and quicker with the SFC system. Thorough patient assessments are completed, and changes in the patient&AElig;s condition are defined clearly. There has been substantial decrease in documentation time and redundancy.<br/><br/>Our quality improvement audits are conducted quickly because of the simplicity of this system's charting. We are finding a completeness in our documentation that was lacking with our former narrative documentation system. The SFC system has been a successful venture in our ED. Emergency nurses should consider implementing a SFC system for their patient care. [Clinical Poster Presentation]</td></tr></table>en_GB
dc.date.available2011-10-27T10:34:19Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:34:19Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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