2.50
Hdl Handle:
http://hdl.handle.net/10755/183102
Category:
Abstract
Type:
Presentation
Title:
Creating a Nurse Friendly Documentation Tool
Author(s):
Schurr, Elizabeth; Spanolios, Anna; Mason, Tina; Smith, Sherri; Carroll, Mary; Lalau, Jennifer; Thirlwell, Sarah
Author Details:
Elizabeth Schurr, RN, OCN, H. Lee Moffitt Cancer Center, Tampa, FL, email: tina.mason@moffitt.org; Anna Spanolios; Tina Mason; Sherri Smith; Mary Carroll; Jennifer Lalau; Sarah Thirlwell
Abstract:
Purpose:
Thorough documentation demonstrates accountability. Challenges arise when time spent documenting increases overtime and compromises quality patient care. Staff desired a more efficient approach to charting that would continue our progress toward electronic documentation. The purpose of this abstract is to discuss the creation of a documentation tool that is user-friendly, efficient and reflects the quality nursing care of a hematology/medical oncology unit.

Method:
Senior staff members, along with the patient care manager and clinical nurse specialist (CNS), collaborated to create a documentation tool that was more functional and specific for their patient population. Capitalizing on previous work by the BMT nursing team in December, 2007, the group chose the most common NANDA nursing diagnoses for hematology patients. The nursing process was continued by adding appropriate assessments, goals and interventions. Finally, an area for additional notation was added for unmet goals or further documentation deemed essential. Nurses began using the new Nursing Progress Note in July, 2008.

Findings:
This approach integrates all the elements of the nursing process. Nursing staff has voiced unanimous positive feedback on the ease of use. The staff also feels that the form has allowed them to completely document all aspects of nursing care in a timely manner and thus has decreased incidental overtime.

Discussion:
This process and outcome are examples of our institution's commitment to shared governance. Staff nurses, working in conjunction with leadership designed a solution that works for them. At present, four sets of population-specific progress notes have been developed and are utilized on all inpatient units. The CNS' monitor its use and need for improvement. Future directions include adapting the form to an electronic medical record format. This has streamlined documentation, increased nurse satisfaction and improved compliance with Joint Commission standards, not to mention given us more time to be with the patients.
Repository Posting Date:
28-Oct-2011
Date of Publication:
28-Oct-2011
Conference Date:
2009
Conference Name:
6th Annual Florida Magnet Research Conference
Conference Host:
University of South Florida College of Nursing; Magnet Hospitals of Florida; Sigma Theta Tau International; Florida Organization of Nurse Executives
Conference Location:
Kissimmee, Florida
Description:
6th Annual Florida Magnet Research Conference � Theme: Research at the Point of Care. Held 12-13 February 2009 at Gaylord Palms Resort and Convention Center, Kissimmee, 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.titleCreating a Nurse Friendly Documentation Toolen_GB
dc.contributor.authorSchurr, Elizabethen_US
dc.contributor.authorSpanolios, Annaen_US
dc.contributor.authorMason, Tinaen_US
dc.contributor.authorSmith, Sherrien_US
dc.contributor.authorCarroll, Maryen_US
dc.contributor.authorLalau, Jenniferen_US
dc.contributor.authorThirlwell, Sarahen_US
dc.author.detailsElizabeth Schurr, RN, OCN, H. Lee Moffitt Cancer Center, Tampa, FL, email: tina.mason@moffitt.org; Anna Spanolios; Tina Mason; Sherri Smith; Mary Carroll; Jennifer Lalau; Sarah Thirlwellen_US
dc.identifier.urihttp://hdl.handle.net/10755/183102-
dc.description.abstractPurpose:<br/>Thorough documentation demonstrates accountability. Challenges arise when time spent documenting increases overtime and compromises quality patient care. Staff desired a more efficient approach to charting that would continue our progress toward electronic documentation. The purpose of this abstract is to discuss the creation of a documentation tool that is user-friendly, efficient and reflects the quality nursing care of a hematology/medical oncology unit. <br/><br/>Method:<br/>Senior staff members, along with the patient care manager and clinical nurse specialist (CNS), collaborated to create a documentation tool that was more functional and specific for their patient population. Capitalizing on previous work by the BMT nursing team in December, 2007, the group chose the most common NANDA nursing diagnoses for hematology patients. The nursing process was continued by adding appropriate assessments, goals and interventions. Finally, an area for additional notation was added for unmet goals or further documentation deemed essential. Nurses began using the new Nursing Progress Note in July, 2008. <br/><br/>Findings:<br/>This approach integrates all the elements of the nursing process. Nursing staff has voiced unanimous positive feedback on the ease of use. The staff also feels that the form has allowed them to completely document all aspects of nursing care in a timely manner and thus has decreased incidental overtime. <br/><br/>Discussion:<br/>This process and outcome are examples of our institution's commitment to shared governance. Staff nurses, working in conjunction with leadership designed a solution that works for them. At present, four sets of population-specific progress notes have been developed and are utilized on all inpatient units. The CNS' monitor its use and need for improvement. Future directions include adapting the form to an electronic medical record format. This has streamlined documentation, increased nurse satisfaction and improved compliance with Joint Commission standards, not to mention given us more time to be with the patients.en_GB
dc.date.available2011-10-28T16:14:38Z-
dc.date.issued2011-10-28en_GB
dc.date.accessioned2011-10-28T16:14:38Z-
dc.conference.date2009en_US
dc.conference.name6th Annual Florida Magnet Research Conferenceen_US
dc.conference.hostUniversity of South Florida College of Nursingen_US
dc.conference.hostMagnet Hospitals of Floridaen_US
dc.conference.hostSigma Theta Tau Internationalen_US
dc.conference.hostFlorida Organization of Nurse Executivesen_US
dc.conference.locationKissimmee, Floridaen_US
dc.description6th Annual Florida Magnet Research Conference � Theme: Research at the Point of Care. Held 12-13 February 2009 at Gaylord Palms Resort and Convention Center, Kissimmee, Florida, 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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