Implementing Monitoring Tools in the Electronic Health Record (EHR) to Improve Nursing Care Plan Documentation

Prior to the Care Plan Audit tool, only 39.98% of patients had updated care plans and 68.66% of patients had updated daily goals. After one (1) month, there was 92% increase in the number of care plans updated. There was a 29% increase in the number of daily goals updated. The Nursing Care Plans are essential to the clinical nursing practice, its documentation on the EHR facilitates the communication and collaboration of the members of the healthcare team with a goal to deliver patient-centered and unified care. The Public Health Emergency waiver for the Nursing Care Plan documentation was instituted in the year 2020 during the Covid pandemic. In the summer of year 2022, the Centers for Medicare & Medicaid Services (CMS) issued a statement to reestablish the pre-pandemic health and safety standards. There is a need to reincorporate the care plan documentation in the nursing process.

Problem: The reinstatement of care plan documentation poses a huge need for education and compliance. The care plan documentation was waived since the COVID pandemic in 2020, nurses need to start documenting the care plan again in 2022. The managers needed a tool to help them monitor care plan documentation activity

Measurement: Weekly tableau report of Unit census, Number and Percentage of updated Daily Goal, Number and Percentage of updated Care Plan, and Number of Expected End Goal Dates was created. These are the elements that nurses must document in the EHR. Run charts were created to track and trend improvements

Analysis: The Donabedian framework model was applied in the planning and implementation of the nursing education, which focused on three components: structure, process, and outcomes. The Clinical Nurse Informatics Specialists (CNIS) implemented a monitoring tool built in the Electronic Health Record (EHR) to support reinstatement of Nursing Care Plan

Implementation: The virtual platform was used for convenient accessibility allowing participants to save time and travel cost. The 30-minute virtual meeting consisted of a step-by-step guidance to add and use the tool on their EHR. The CNIS discussed each element of the tool allowing for questions and feedback in real-time

Clinical Nurse Informatics Specialist at Yale New Haven Hospital
Clinical Nurse Informatics Specialist – Yale New Haven Hospital

Speaker Type: Poster Presentations On-Demand

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