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Achieving our goals of zero preventable injuries and deaths and 90th percentile performance in national quality measures requires both good nursing care and good documentation that supports patient safety and allows for data retrieval to meet those objectives. This project involved establishment of  a regional team from five hospitals within a larger hospital system, securing internal funding, gaining support for the project at the top administrative levels, and shepherding the project through planning, implementation and analysis phases.  The presentation will include aspects of these three phases and the important lessons learned during the process.

Building a regional perinatal documentation program is an innovative project based on dissemination of best computer documentation practice.  This project recognized that evidence-based care must be provided by a seamless care team complemented by complete and accurate documentation of that care. The intention was to form a clinical/IT partnership to maximize use of perinatal documentation systems in each of the five hospitals in the region.  This partnership was anticipated to help develop best practice for perinatal documentation and maximize computer efficiency within our region and create the algorithms to deploy these evidence-based documentation practices.

Documentation consumes excessive amounts of nursing time and directly influences the quality of clinical practice, research, administration and education.  Poor documentation of care not only impedes communication among providers, but often complicates defense against malpractice claims.  A perinatal computer documentation process must make best use of information technology and clinical practice.  Standardizing perinatal patient documentation and integrating required documentation from the general hospital documentation system is anticipated to result in an improvement in the baseline standard of practice and a reduction in medical-legal risk associated with perinatal nursing documentation.  Additional anticipated results include perinatal nursing satisfaction, perinatal manager/director satisfaction related to streamlined clinical documentation and data collection, increased time nurses spend in direct patient care, and standardized evidence based nursing documentation to reflect quality care provided by the care team.  Analyzing the current structure of perinatal computer documentation; analyzing the processes involved in integrating existing modalities will lead to improved outcomes and raise the quality of care.