Transform Nursing Documentation

Ann OBrien, RN, MSN1 and Charlotte A. Weaver RN, PhD, FAAN2
Kaiser Permanente, IT & National Patient Care Services1 ; Healthcare Executive and NI Pioneer2
Data Rich and Information Poor Factor of Nursing Clinical Documentation

Accomplishments

Recommendations

Developed Set of Recommendations

Spread best practices for EHR

documentation, decision support & data
visualization
Provide knowledge at the point of care to
support evidence based practice
Design clinical content with dynamic links that
update with new evidence
Demonstrate patients condition in real time
using all data collected
Address care gaps across the continuum
Build care plans that are patient centered,
inter-disciplinary, dynamic & transparent
Utilize predictive analytics tools to present
changes in patient status
Provide links to knowledge sources,
calculators, libraries, protocols in real time
Display information across disciplines,
encounters of care to show trends, risks,
progress toward goals
Eliminate duplicate documentation
Personalize care based on evidence based
practice, patient needs, preferences and
shared decision making
Make information actionable to improve
efficiency / usability

Disseminate skills in mapping EHR terms

to SNOMED-CT & LOINC
Standardize processes; keep vendor neutral
Teach competencies in Nursing Informatics at
BS and MS levels.

Objectives
Determine infrastructures needed within EHRs and data
repositories to enable the storage, aggregation, and
querying of nursing data at an organizational level, as well
as exchange data at a national or international level to
support quality outcomes, practice based evidence and
knowledge representation
Collaborate with diverse leaders from practice, academia
and vendors on a set of recommendations for integrating
the best clinical knowledge into care decisions
Propose opportunities to support the nursing process
within EHRs and capture nursings contribution to quality,
safety, highly reliable care and patient engagement

Action Plan

WG10 members successfully gained consensus on

current state. Issues and describing the problems
encountered by front line nurses and managers
Developed set of recommendations to counter the
problematic areas of documentation burden, lack
of clinical decision support and data visualization.
Critical need to avoid cost of each organization
building nursing content from scratch
Paper for Nursing Admin Quarterly in process

Next Steps
Develop | Plan | Operationalize | Disseminate

Promote Need of Repository of Best Practices

Would include examples and design principles for:
clinical forms and workflow; examples of clinical
documentation forms; use of standardized
terminology showing mapping to SNOMED-CT &
LOINC; CDS multiple types; and reporting
Work with NI community of experts and organizations
to generate, collect content
Present business case through conference
presentations and publications Nursing, Health
Policy and Informatics
Develop plan for operationalizing: housing,
maintenance, and collection

Collaborate with other Big Data Working Groups

for:
Seek guidance identifying resource for housing
national nursing repository of clinical content ,
evidence based bundles, CDS
Recruit for volunteers and within NI community,
WGs for best practice examples for repository and
content sharing