Forging New Pathways to Integrate Nursing Practice Across a Health System
- Discuss strategies in standardizing clinical documentation across a health system.
- Identify challenges in promoting a complete comprehesive EMR.
- Discuss examples of work flow processes and documentation quidelines.
Purpose for the progam: To continue our health system progess towards a complete EMR in obstetrics
A strategic priority of Duke University Health System (DUHS) mission, vision, and values is the development of a complete electronic medical record. The advent of recent regulations for Meaningful Use mandates makes this critical to our clinical and business success. Women’s Services has been actively engaged over the past ten years to maximize the capability and use of the existing perinatal information system to meet this goal. It is in the gathering and strategic use of accessible information about the patient, about care provided, and outcomes that we are able to measure and improve care. DUHS continues to be a leader in the implementation and progressive use of the Perinatal Electronic Medical Record (EMR).
Proposed change: To design and support electronic clinical documentation relative to clinical pathways and nursing diagnoses for mothers and newbornsImplication for nursing practice:
Readily available information at the point of care across health system and continuum of care
Implementation, outcomes and evaluation: In an attempt to standardize nursing practice across a health system consisting of a large academic medical center and a community hospital, a Joint Clinical Practice Committee was established. The joint committee’s initial challenge was to clarify definitions, identify current work flow processes, and develop new documentation guidelines. The team worked to design and support electronic clinical documentation relative to clinical pathways and nursing diagnoses for mothers and newborns.
Education and implementation strategies were designed and standardized to meet the new goals. The team evolved and changed over the course of the initial process and a strong collaboration was formed. The joint committee solicited feedback from the staff and remained focused on its mission. New documentation templates were designed to support the individualization of nursing care plans and interventions for mothers and newborns. These templates replaced the current paper format at both hospitals. Our outcome completes the final step to becoming a complete perinatal electronic patient record.
Inmplications for nursing practice: Promotes adherence to Meaningful Use mandates
Keywords: Standardized documentation; Electronic Medical Record; Clinical Maps
Clinical Pathways
Purpose for the program:, Proposed change:, Implementation, outcomes and evaluation:, Implications for nursing practice: and Keywords:
Purpose for the program:
