Collaboration is the Key

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A new documentation system is never easy
By Jennifer Walker

Nurse Holding Tablet PCBuilding, testing, and implementing an electronic nursing documentation system is a complex process. In fact, for Johns Hopkins Bayview Medical Center’s Emergency Department, it took eight months of planning, analyzing, and revising plans. But the work of nurses, clinical analysts, and “super user” trainers has paid off in the form of a seamless transition from recording triage notes on paper to computerized documentation.

“I believe the success is due to detailed planning, key stakeholder involvement and buy-in, and good communication across many different disciplines,” says Carrie Stein, MSN, RN, Director of Nursing Informatics and Evaluation Research.

The project was led by Clinical Information Analyst, Kim Foltz, MS, RN, who was primarily responsible for building the system, and Clinical Nurse Specialist, Ilene Jones, MS, RN, who coordinated user trainings and served as the liaison between the nursing staff and the clinical analysts.

As the clinical liaison, Jones first needed to determine the system requirements for staff to provide optimal patient care. She met with staff nurses and took their ideas to the analysts, who determined how the requirements matched the software’s capabilities.

“The analysts [then]had to build a system with screens that flowed smoothly and matched the workflow of the nurses,” says Foltz. “It also had to have reporting functions so staff could quickly print a summary of triage information.”

Once the system was ready, Jones coordinated trainings for staff led by a team of five “super users”—nurses who received special training in using the system. This team demonstrated the software to their peers, and also provided support on the unit after the system went live in late April.

Because of this coordinated effort, ED staff feel that the new nursing documentation system has improved patient care in just six weeks.

“Before [the system], nurses spent a lot of time looking for paper charts,” says Kirk Koneval, RN, one of the “super user” nurses. “Now nurses will have more time to document everything we do.”

Patient Care Manager Joanne Renjel, RN, agrees. “The system has allowed nursing staff to spend more time at the bedside. It’s a ‘win-win’ situation for all.”

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