2.50
Hdl Handle:
http://hdl.handle.net/10755/164160
Category:
Abstract
Type:
Presentation
Title:
Surfing the Waves of Change: CNS Role in Creating a Foundation for Computerized Documentation
Author(s):
Stark, Susan
Author Details:
Susan Stark, MSN, RN, APRN, BC, CNS, Shawnee Mission Medical Center, Shawnee, Kansas, USA, email: nacnsorg@nacns.org
Abstract:
Statement of Problem: Our narrative documentation system lacked definitive descriptors and the ability to support the evaluation of nursing processes. The hospital also had a strategic plan to implement an electronic medical record (EMR). Together, the opportunity existed to design a documentation framework creating a synergistic relationship between best nursing practices and computerization. Purpose: To develop documentation philosophy and structural framework based on evidence and standards of care that captures the essence of nursing practice and facilitate the transition to computerization. Description: In preparation for computerization, a new paper documentation system was created based on a framework of defined descriptors and protocols. The protocols and specific nursing care sets represented evidenced-based nursing practice and structure for the EMR. Method: Key stakeholders from each nursing practice area were recruited to the documentation committee. Following an intensive literature review, including the ANA documentation and JCAHO standards, definitive descriptors were identified. Practice Council used evidence and standards of care to develop practice protocols. The CNS was positioned to facilitate the development of a documentation framework. The written system was then piloted, refined, and implemented throughout the hospital. Evaluation: The act of defining best practices increased nursing ownership of patient care standards and outcomes. JCAHO recognition of the documentation system as "best practice" added validity to the product. Our protocols and descriptors are streamlining the transition to EMR for our hospital and others in our system Implications for Practice: Operationalization of best practice documentation facilitates outcome measurement and process improvement. This allows the CNS, and others, to evaluate the effectiveness of clinical practice.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2005
Conference Name:
CNS Leadership: Navigating the Healthcare Environment Toward Excellence
Conference Host:
NACNS - National Association of Clinical Nurse Specialists
Conference Location:
Orlando, Florida, USA
Description:
Conference theme: CNS Leadership: Navigating the Healthcare Environment Toward Excellence, held on March 9�12, 2005 in Orlando, Florida, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleSurfing the Waves of Change: CNS Role in Creating a Foundation for Computerized Documentationen_GB
dc.contributor.authorStark, Susanen_US
dc.author.detailsSusan Stark, MSN, RN, APRN, BC, CNS, Shawnee Mission Medical Center, Shawnee, Kansas, USA, email: nacnsorg@nacns.orgen_US
dc.identifier.urihttp://hdl.handle.net/10755/164160-
dc.description.abstractStatement of Problem: Our narrative documentation system lacked definitive descriptors and the ability to support the evaluation of nursing processes. The hospital also had a strategic plan to implement an electronic medical record (EMR). Together, the opportunity existed to design a documentation framework creating a synergistic relationship between best nursing practices and computerization. Purpose: To develop documentation philosophy and structural framework based on evidence and standards of care that captures the essence of nursing practice and facilitate the transition to computerization. Description: In preparation for computerization, a new paper documentation system was created based on a framework of defined descriptors and protocols. The protocols and specific nursing care sets represented evidenced-based nursing practice and structure for the EMR. Method: Key stakeholders from each nursing practice area were recruited to the documentation committee. Following an intensive literature review, including the ANA documentation and JCAHO standards, definitive descriptors were identified. Practice Council used evidence and standards of care to develop practice protocols. The CNS was positioned to facilitate the development of a documentation framework. The written system was then piloted, refined, and implemented throughout the hospital. Evaluation: The act of defining best practices increased nursing ownership of patient care standards and outcomes. JCAHO recognition of the documentation system as "best practice" added validity to the product. Our protocols and descriptors are streamlining the transition to EMR for our hospital and others in our system Implications for Practice: Operationalization of best practice documentation facilitates outcome measurement and process improvement. This allows the CNS, and others, to evaluate the effectiveness of clinical practice.en_GB
dc.date.available2011-10-27T11:43:09Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:43:09Z-
dc.conference.date2005en_US
dc.conference.nameCNS Leadership: Navigating the Healthcare Environment Toward Excellenceen_US
dc.conference.hostNACNS - National Association of Clinical Nurse Specialistsen_US
dc.conference.locationOrlando, Florida, USAen_US
dc.descriptionConference theme: CNS Leadership: Navigating the Healthcare Environment Toward Excellence, held on March 9�12, 2005 in Orlando, Florida, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.en_US
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