10.00
Hdl Handle:
http://hdl.handle.net/10755/182240
Category:
Abstract
Type:
Presentation
Title:
Electronic Care Plans Using SNL - Getting to the Point and Making it Click
Author(s):
Hafner, Jennifer
Author Details:
Jennifer Hafner, RN, BSN, TNCC, Aspirus Wausau Hospital, Wausau, Wisconsin, USA, email: jennifro@aspirus.org
Abstract:
Modifications of an electronic medical record (EMR) implemented in December 2006 brought a hospital to the forefront of nursing documentation using NANDA, NIC and NOC standardized nomenclature. The use of the standardized nursing languages of NANDA (North American Nursing Diagnosis Association), NIC (Nursing Interventions Classification), and NOC (Nursing Outcomes Classification) in a measurable, and user-friendly format using the Care Plan activity in the EMR system has allowed the hospital to be a leader in nursing documentation. It also supports the commitment to evidence based nursing practice. A nurse-lead taskforce consulted with experts and created specific workflow designs to manipulate the care plan activity in the EMR. This allows each care plan to be individualized to each patient as required by the Joint Commission. Over one-hundred and forty comprehensive care plans were created to allow for an easy workflow for nurses. Each care plan follows evidenced-based nursing practice guidelines and enhances critical thinking. The taskforce has developed into a standing committee that monitors the care plans, revises based on current nursing practice, and creates new ones as needed. The committee also develops and submits new terms for inclusion in the nomenclatures as needed, and serves as a resource in the hospital. The project was an overall success, by displaying positive outcomes in nursing documentation. References: North American Nursing Diagnosis International. (2007). Nursing diagnoses: Definitions and classification 2007-2008. Philadelphia: NANDA International.; Ackley, B. J., Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed.). St. Louis: Mosby.; Epic Systems Corporation (2002). (Epic 2002 MU4) [Computer software] Verona, WI: Epic Systems Corporation.; Epic Systems Corporation (2005). (Epic Spring 2005 SU05) [Computer software] Verona, WI: Epic Systems Corporation.; McCloskey Dochterman, J., & Bulechek, G. M. (Eds.). (2008). Nursing interventions classification (5th ed.). St. Louis: Mosby.; Moorhead, S., Johnson, M., & Maas, M. (Eds.). (2008). Nursing outcomes classification (4th ed.). St. Louis: Mosby.
Repository Posting Date:
28-Oct-2011
Date of Publication:
28-Oct-2011
Conference Date:
2009
Conference Name:
ANCC National Magnet Conference
Conference Host:
American Nurses Credentialing Center
Conference Location:
Louisville, Kentucky, USA
Description:
"Magnet: Inspiring Innovation, Achieving Outcomes" was the theme and "Explore the relationship among leadership, innovation, and nursing practice outcomes" was the goal of the 13th American Nurses Credentialing Center (ANCC) National Magnet Conference, held 1-3 October, 2009 in Louisville, Kentucky, 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.titleElectronic Care Plans Using SNL - Getting to the Point and Making it Clicken_GB
dc.contributor.authorHafner, Jenniferen_US
dc.author.detailsJennifer Hafner, RN, BSN, TNCC, Aspirus Wausau Hospital, Wausau, Wisconsin, USA, email: jennifro@aspirus.orgen_US
dc.identifier.urihttp://hdl.handle.net/10755/182240-
dc.description.abstractModifications of an electronic medical record (EMR) implemented in December 2006 brought a hospital to the forefront of nursing documentation using NANDA, NIC and NOC standardized nomenclature. The use of the standardized nursing languages of NANDA (North American Nursing Diagnosis Association), NIC (Nursing Interventions Classification), and NOC (Nursing Outcomes Classification) in a measurable, and user-friendly format using the Care Plan activity in the EMR system has allowed the hospital to be a leader in nursing documentation. It also supports the commitment to evidence based nursing practice. A nurse-lead taskforce consulted with experts and created specific workflow designs to manipulate the care plan activity in the EMR. This allows each care plan to be individualized to each patient as required by the Joint Commission. Over one-hundred and forty comprehensive care plans were created to allow for an easy workflow for nurses. Each care plan follows evidenced-based nursing practice guidelines and enhances critical thinking. The taskforce has developed into a standing committee that monitors the care plans, revises based on current nursing practice, and creates new ones as needed. The committee also develops and submits new terms for inclusion in the nomenclatures as needed, and serves as a resource in the hospital. The project was an overall success, by displaying positive outcomes in nursing documentation. References: North American Nursing Diagnosis International. (2007). Nursing diagnoses: Definitions and classification 2007-2008. Philadelphia: NANDA International.; Ackley, B. J., Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed.). St. Louis: Mosby.; Epic Systems Corporation (2002). (Epic 2002 MU4) [Computer software] Verona, WI: Epic Systems Corporation.; Epic Systems Corporation (2005). (Epic Spring 2005 SU05) [Computer software] Verona, WI: Epic Systems Corporation.; McCloskey Dochterman, J., & Bulechek, G. M. (Eds.). (2008). Nursing interventions classification (5th ed.). St. Louis: Mosby.; Moorhead, S., Johnson, M., & Maas, M. (Eds.). (2008). Nursing outcomes classification (4th ed.). St. Louis: Mosby.en_GB
dc.date.available2011-10-28T15:15:21Z-
dc.date.issued2011-10-28en_GB
dc.date.accessioned2011-10-28T15:15:21Z-
dc.conference.date2009en_US
dc.conference.nameANCC National Magnet Conferenceen_US
dc.conference.hostAmerican Nurses Credentialing Centeren_US
dc.conference.locationLouisville, Kentucky, USAen_US
dc.description"Magnet: Inspiring Innovation, Achieving Outcomes" was the theme and "Explore the relationship among leadership, innovation, and nursing practice outcomes" was the goal of the 13th American Nurses Credentialing Center (ANCC) National Magnet Conference, held 1-3 October, 2009 in Louisville, Kentucky, USA.en_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.-
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