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Nursing documentation is a ‘record of compliance’ legislated by a professional governing body and organizational policy. But does this data reflect nursing knowledge, the care provided and most importantly outcomes? The ‘meaningful use’ of technology (Thede, 2008) can have measurable impact on nursing care and better health outcomes for patients.
At a 472 bed academic health science centre the goal of Nursing Informatics is to fully integrate an electronic health record to support and improve the delivery of patient care and experience by maximizing the benefits of new technologies, support evidence-based nursing practice, the acquisition of nursing knowledge and both clinical and administrative decision-making.
As a Best Practice Spotlight Organization, the Best Practice Ostomy Team partnered with Nursing Informatics and Informatics Department to redesign the electronic ostomy care documentation system and adopt the Ostomy Skin Tool (Jemec et al, 2011). Recognized as a recommendation by the Registered Nurses Association of Ontario (RNAO, 2009) the electronic implementation of a validated classification tool to monitor peristomal complications was implemented to leverage evidence-based nursing practice and advance nursing knowledge from a basic passive approach to an advanced active approach toward critical-thinking.
Purpose
Demonstrate the process used to partner in the design and implementation of an evidence-based peristomal assessment tool into an electronic patient record system.
Method
The process will address the steps used toward achieving implementation:
- Partnership of key stakeholders
- Evaluation of the current and future documentation template
- Educational preparation of nursing staff
- Timeline from initiation to final deliverable
- Challenges and opportunities
Results
Post implementation data will be shared.
Implications to Practice/ Conclusion
Earlier documentation lacked rigor, description and practice impact was irretrievable. The Informatics Department has enabled Enterostomal Therapy nursing to capture data based on a validated and standardized approach to care delivery and measureable outcomes in ostomy care.