Instituting an Electronic Nursing Plan of Care-The ImPaCTT Project at Integris Health-Improving Patient Care Through Technology

8.00
Hdl Handle:
http://hdl.handle.net/10755/164363
Category:
Abstract
Type:
Presentation
Title:
Instituting an Electronic Nursing Plan of Care-The ImPaCTT Project at Integris Health-Improving Patient Care Through Technology
Author(s):
Burnette, Daphne; Winningham, Marci; Hartzel, Doug
Author Details:
Daphne Burnett, MS, RN, CCNS, CNS, Integris Health, Mustang, Oklahoma, USA, email: nacnsorg@nacns.org; Marci Winningham, MS, RN, CCNS, CNS; Doug Hartzell, RN, MHR
Abstract:
Purpose: To provide clinicians with a comprehensive electronic Nursing Plan of Care(POC) for Acute Care patients utilizing NANDA nursing language. Background/Significance: Providing adequate documentation of patient care is always an ongoing struggle in any institution. Meeting JCAHO requirements is also a struggle when it comes to documentation of the POC. Integris Health in Oklahoma City has worked with the Cerner system towards providing an EMR. Integris Southwest Medical Center achieved great success with the placing the Admitting Patient History form on-line and making pertinent fields required items in order for the history to show complete during electronic auditing. The CNS's identified the Nursing POC as an important part of the patient medical record that is not always completed by the nursing staff with their current documentation utilizing the FOCUS system. Creating an EMR Nursing POC that would compliment the pieces of medical record currently electronic would not only benefit the nursing staff but would achieve all the JCAHO requirements necessary in planning patient care. Description of the Project: Together with the Care Net Systems manager, the CNS's worked to provide a comprehensive POC looking at each system identified within the current FOCUS documentation. The group initially met with Nursing leadership and the leadership of the ImPaCTT project at Integris Health. The ImPaCTT project oversees all of the EMR at Integris Health. During this meeting many ideas were discussed as well as what body of nursing language to utilize for the POC. After this meeting the CNS's researched various nursing languages including NIC, NOC, and NANDA. It was then decided to utilize NANDA as the core for the nursing POC. Each Focus section currently used at Integris Health was looked at individually and Nursing Diagnosis, Nursing Goals, Nursing Actions and Patient Responses were identified. The program was built so that an individual Nursing Diagnosis was identified and a Goal established. As the nurse documents he/she can identify numerous actions for each diagnosis and goal. A response is also identified as ongoing or resolved. The nurse clicks on the box next to the item selected for the patients' POC, which simplifies the computerized process for the end-user. Outcomes: A pilot study utilizing a medical/surgical unit at Integris Southwest Medical Center was utilized to roll out the Nursing POC. Minimal education was required on how to fill out the form due to current computer knowledge with other EMR's utilized at Integris Health. Evaluation: During the pilot it was recognized that a few areas in the POC were not available based on utilization of the FOCUS sections. The main section missing related to endocrine type disorders. Currently the CNS's are working to add this section to the POC and will be utilizing this house wide in June of 2004.
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.titleInstituting an Electronic Nursing Plan of Care-The ImPaCTT Project at Integris Health-Improving Patient Care Through Technologyen_GB
dc.contributor.authorBurnette, Daphneen_US
dc.contributor.authorWinningham, Marcien_US
dc.contributor.authorHartzel, Dougen_US
dc.author.detailsDaphne Burnett, MS, RN, CCNS, CNS, Integris Health, Mustang, Oklahoma, USA, email: nacnsorg@nacns.org; Marci Winningham, MS, RN, CCNS, CNS; Doug Hartzell, RN, MHRen_US
dc.identifier.urihttp://hdl.handle.net/10755/164363-
dc.description.abstractPurpose: To provide clinicians with a comprehensive electronic Nursing Plan of Care(POC) for Acute Care patients utilizing NANDA nursing language. Background/Significance: Providing adequate documentation of patient care is always an ongoing struggle in any institution. Meeting JCAHO requirements is also a struggle when it comes to documentation of the POC. Integris Health in Oklahoma City has worked with the Cerner system towards providing an EMR. Integris Southwest Medical Center achieved great success with the placing the Admitting Patient History form on-line and making pertinent fields required items in order for the history to show complete during electronic auditing. The CNS's identified the Nursing POC as an important part of the patient medical record that is not always completed by the nursing staff with their current documentation utilizing the FOCUS system. Creating an EMR Nursing POC that would compliment the pieces of medical record currently electronic would not only benefit the nursing staff but would achieve all the JCAHO requirements necessary in planning patient care. Description of the Project: Together with the Care Net Systems manager, the CNS's worked to provide a comprehensive POC looking at each system identified within the current FOCUS documentation. The group initially met with Nursing leadership and the leadership of the ImPaCTT project at Integris Health. The ImPaCTT project oversees all of the EMR at Integris Health. During this meeting many ideas were discussed as well as what body of nursing language to utilize for the POC. After this meeting the CNS's researched various nursing languages including NIC, NOC, and NANDA. It was then decided to utilize NANDA as the core for the nursing POC. Each Focus section currently used at Integris Health was looked at individually and Nursing Diagnosis, Nursing Goals, Nursing Actions and Patient Responses were identified. The program was built so that an individual Nursing Diagnosis was identified and a Goal established. As the nurse documents he/she can identify numerous actions for each diagnosis and goal. A response is also identified as ongoing or resolved. The nurse clicks on the box next to the item selected for the patients' POC, which simplifies the computerized process for the end-user. Outcomes: A pilot study utilizing a medical/surgical unit at Integris Southwest Medical Center was utilized to roll out the Nursing POC. Minimal education was required on how to fill out the form due to current computer knowledge with other EMR's utilized at Integris Health. Evaluation: During the pilot it was recognized that a few areas in the POC were not available based on utilization of the FOCUS sections. The main section missing related to endocrine type disorders. Currently the CNS's are working to add this section to the POC and will be utilizing this house wide in June of 2004.</td></tr></table>en_GB
dc.date.available2011-10-27T11:47:00Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T11:47:00Z-
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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