Nursing documentation in electronic health records (EHRs) allows nurses to quantify their impact on patient outcomes. Developing an EHR system for a community nursing organization required defining data requirements, selecting software, and testing prototypes. The system's documentation concepts include assessments, care plans, and progress notes. Nurses can access client records, schedules, procedures, and messaging on mobile tablets in the field. Effective nursing documentation in EHRs demonstrates nursing's contribution to patient care and outcomes.

1. Nursing Documentation in an EHR
National Nursing Informatics Conference October 2015
Sheree East

2. The value of nursing services will continue
to remain unrecognised if quantifiable data
remains unavailable to prove the
relationship between the care provided by
nurses and patient outcomes.
Saba & Taylor 2007

3. Improving health outcomes and
wellbeing through community care
since 1896

4. The Challenge
Providing useful usable information
that makes a difference to patient care

5. Nurse Maude EHR development
Data
Dictionary
Requirements
Software
specifications
Vendor
selection
Development
Prototype
Pilot
Requirements
Development
Testing
Field Testing
Process
mapping
User
manuals
Training
Materials
User training

6. Documentation Concepts

7. Assessment
Diagnosis
Care Plan
Progress
Note
Outcomes
Recognisable

8. Standardised

9. Easy to use

10. Design

11. Design decisions
Adapted from shakthydoss.com
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or

12. Omaha System problems and interventions
for New Zealand District Nursing?

13. Care Pathways
Core Pathway # Pathway Problems
District Nursing 15
Home Care 3
Rehab 3
Dialysis 1
Palliative Care 15

14. District Nursing Pathway (Skin)
Pathway
problem
Pathway interventions Care
Instructions
Skin Anatomy/
physiology
Laboratory
findings
Pick from
Protocols list or
specific
instructionBehaviour
modification
Nursing care
Continuity of
Care
Signs /
symptoms
physical
Dietary
management
Dressing
change / wound
care

15. Progress Notes

16. The client record
• Demographics
• Alerts
• Service allocations
• Encounters
• Status
• Scanned documents
• Clinical documentation
– Assessment
– Problem List
– Care pathway
– Care plan
– Vitals
– Progress notes
– Outcome measures
On my tablet
• Daily visit schedule
• Client details
• Client record
• Decision support
• Health pathways
• Lippencott procedures
• Medsafe
• Nurse Maude Policy & Procedures
• Secure messaging (HL7)
• HealthOne
• Incident reporting
• Image capture
• My calendar
• My email
• Street maps
CRISTA

17. Key messages

18. The Challenge for nursing is to ensure
that nursing data is collected,
transmissible, and identifiable within
the record, and ultimately that nursing
is able to demonstrate its contribution
to clinical outcomes.

19. Thank you

20. sheree.east@nursemaude.org.nz