2.50
Hdl Handle:
http://hdl.handle.net/10755/182547
Category:
Abstract
Type:
Presentation
Title:
Improving Nursing Documentation to "Tell the Patient's Story"
Author(s):
Michel, Marti; Stanley, Terry; Naessens, Jennifer
Author Details:
Marti Michel, MSN, RN, CPNP, Riley Hospital for Children, Clarian Health Partners, Indianapolis, Indiana, USA, email: mmichel@clarian.org; Terry Stanley, MSN, RN; Jennifer Naessens
Abstract:
Poster Presentation: Documentation is an essential component of nursing care. Beyond meeting regulatory and legal requirements, documentation provides an opportunity to communicate "the story of the patient and family" to the health care team. Skilled communication is cited as a critical element in promoting a culture of safety and excellence and promoting true collaboration. In our acute care children's hospital, charting by exception was implemented to improve efficiency and reduce the burden of nursing documentation. Over time this method evolved into documenting only what the flow sheet required, resulting in 'gaps" in the patient's story. We convened a group of nursing leadership, clinical nurse specialists, clinical educators and staff nurses to develop processes and new documentation tools to facilitate the comprehensive documentation by nurses of pertinent positives and negatives. These processes and new tools help the nurse use his/her clinical judgment to decide what important information others need to understand the patient's condition and needs. Among our goals was improving performance on nursing sensitive indicators while enhancing patient outcomes, facilitating communication and collaboration and providing an environment conducive to nurses "growing" their professional practice. Other goals include creating a culture of accountability among nurses for completeness of documentation and making a transformation improvement in providing family centered care. This poster will describe the three phases of our documentation improvement initiative and share our lessons learned along the way. The phases include: 1) introduction of new documentation standards including new forms integral to our goals; 2) implementation and standardization of a new bedside report including parents; and 3) introduction of a new nursing flowsheet and implementation of a standardized handoff between units. Throughout these three phases we utilized an intensive education blitz coupled with...[Please contact the primary investigator for more information about this poster presentation.] REFERENCES: American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Health Work Environments: A Journey to Excellence. Aliso Viejo, California: American Association of Critical-Care Nurses; 2005.
Repository Posting Date:
28-Oct-2011
Date of Publication:
28-Oct-2011
Conference Date:
2008
Conference Name:
ANCC National Magnet Conference
Conference Host:
American Nurses Credentialing Center
Conference Location:
Salt Lake City, Utah, USA
Description:
The 12th American Nurses Credentialing Center (ANCC) National Magnet Conference, held 15-17 October, 2008 in Salt Lake City, Utah, 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.titleImproving Nursing Documentation to "Tell the Patient's Story"en_GB
dc.contributor.authorMichel, Martien_US
dc.contributor.authorStanley, Terryen_US
dc.contributor.authorNaessens, Jenniferen_US
dc.author.detailsMarti Michel, MSN, RN, CPNP, Riley Hospital for Children, Clarian Health Partners, Indianapolis, Indiana, USA, email: mmichel@clarian.org; Terry Stanley, MSN, RN; Jennifer Naessensen_US
dc.identifier.urihttp://hdl.handle.net/10755/182547-
dc.description.abstractPoster Presentation: Documentation is an essential component of nursing care. Beyond meeting regulatory and legal requirements, documentation provides an opportunity to communicate "the story of the patient and family" to the health care team. Skilled communication is cited as a critical element in promoting a culture of safety and excellence and promoting true collaboration. In our acute care children's hospital, charting by exception was implemented to improve efficiency and reduce the burden of nursing documentation. Over time this method evolved into documenting only what the flow sheet required, resulting in 'gaps" in the patient's story. We convened a group of nursing leadership, clinical nurse specialists, clinical educators and staff nurses to develop processes and new documentation tools to facilitate the comprehensive documentation by nurses of pertinent positives and negatives. These processes and new tools help the nurse use his/her clinical judgment to decide what important information others need to understand the patient's condition and needs. Among our goals was improving performance on nursing sensitive indicators while enhancing patient outcomes, facilitating communication and collaboration and providing an environment conducive to nurses "growing" their professional practice. Other goals include creating a culture of accountability among nurses for completeness of documentation and making a transformation improvement in providing family centered care. This poster will describe the three phases of our documentation improvement initiative and share our lessons learned along the way. The phases include: 1) introduction of new documentation standards including new forms integral to our goals; 2) implementation and standardization of a new bedside report including parents; and 3) introduction of a new nursing flowsheet and implementation of a standardized handoff between units. Throughout these three phases we utilized an intensive education blitz coupled with...[Please contact the primary investigator for more information about this poster presentation.] REFERENCES: American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Health Work Environments: A Journey to Excellence. Aliso Viejo, California: American Association of Critical-Care Nurses; 2005.en_GB
dc.date.available2011-10-28T15:29:07Z-
dc.date.issued2011-10-28en_GB
dc.date.accessioned2011-10-28T15:29:07Z-
dc.conference.date2008en_US
dc.conference.nameANCC National Magnet Conferenceen_US
dc.conference.hostAmerican Nurses Credentialing Centeren_US
dc.conference.locationSalt Lake City, Utah, USAen_US
dc.descriptionThe 12th American Nurses Credentialing Center (ANCC) National Magnet Conference, held 15-17 October, 2008 in Salt Lake City, Utah, 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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