The care and outcomes management plan and Kardex. A design for improving documentation of nursing plan of care and patient outcomes.
The gradual transition from paper records to electronic records presents challenges for nurses. In particular, split paper/electronic records can interfere with staff communication during shift change reports. A project was implemented to facilitate documentation of individualized care plans and improve staff communication during shift change report. The hospital's critical pathway was incorporated into Kardex to create a single electronic medical record for use during shift change report. This combined electronic outcomes plan and Kardex improved access to patient information during shift report and facilitated nurses' ability to update the care plan with the most current patient information. Future strategies will include collaboration with the hospital's information systems staff to make the COMPdex compatible with the hospital's electronic documentation system, so that pertinent patient data will populate from the current electronic chart into the COMPdex forms for printing and to include patient outcome data in the electronic medical record.
Crabtree
Carole
C
Shriners Hospitals for Children, USA.
Howard
Patricia B
PB
El-Mallakh
Peggy
P
D019091:Critical Pathways; D004282:Documentation / Q000592:standards*; D001330:Electronic Data Processing; D006751:Hospital Information Systems; D006801:Humans; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning / Q000458:organization & administration*