An integrated Perinatal computerized documentation system.

Proposed change:

The Proposed chage was moving from a "stand alone" Labor and Documentation computerized documentation system (including fetal monitoring) to an integrated Perinatal computerized system. This system is accessible throughout the institution as well via remote access. It is integrated with the institution's "main frame" computerized documentation.

Implementation, outcomes and evaluation:

Implementation of the computerized documentation was completed in several phases, starting with Postpartum, Normal Newborn Nursery and the Neonatal Intensive Care Nursery. Labor and Delivery went live with the Antepartum and Intrapartum piece, while the computerized fetal monitoring was the last to be implemented.

Outcomes have included the benefit of the entire perinatal system being able to view the maternal and newborn delivery data in one system, as opposed to the hybrid system that existed prior. The fetal monitoring surveillance is now able to be utilized in several areas across the institution: the Emergency Department, the Intensive Care Unit, as well as an operating room in the main OR. An anticipated outcome is the ability to pull reports from the data documentation. This has so far included types of deliveries, use of provider ordersets, audits of nursing documentation, as well as capturing delivery elements.

Implications for nursing practice:

Implications for nursing practice include ease of reviewing data, of capturing data for reports, as well as the potential for earlier recognition of patient abnormal values, thus increasing quality patient care.

Keywords:

Perinatal computerized documentation, OB documentation systems, change theory