Documentation Rules

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Bedside Nurses Learn New Technology

by Whitney L. J. Howell

IOM Recommendation 2In nursing, documentation rules. Historically, that’s meant binders with patient-care details. Today, it’s navigating multi-layered digital systems. To help nurses master these technologies, The Johns Hopkins Hospital launched the Clinical Informatics Leadership Committee (CILC).

“The impact on bedside nurses is huge,” says Donna Beitler, MS, RN-BC, CGRN, a CILC member and adult medicine nurse. “They have a place to ask questions, a place where they can seek help for things they don’t understand.”

The CILC’s unit-based informatics leaders meet semimonthly to create high-tech strategies that nurses can use to provide quality and evidence-based care. On adult medicine units, for example, electronic health records prompt nurses to check patients’ vaccine status before discharge. In the emergency department, nurses track triage-to-provider time.

In all units, CILC members are supporting the process of identifying successful evidence-based practices and using clinical decision support to offer superior care. The types of data they collect and the ways the data shape their nursing practice differ for each unit.

Donna Beitler, MS, RN-BC, CGRN, a CILC nurse who offers technology skills classes, says informatics data revealed that cooling cardiac arrest patients is a best practice, so adult medicine nurses instituted a hypothermia protocol. In pediatrics, says nursing consultant Catherine Garger, RN, data highlighted that daily catheter changes distress children. The nurses altered the urinary catheter protocol and now change them on an as-needed basis. And in the emergency department, nurses track time from admission to discharge, and the CILC helped improve efficiency, said Heather Gardner, RN.

The CILC’s success stems largely from good two-way communication—from the bedside to the informatics experts and back again.

When bedside nurses have issues or suggestions, “they alert us,” said Debra Sherman, RN, CILC clinical leader and systems development manager. And when the changes or safety issues arise, “CILC ensures the information gets to the bedside nurse. It’s been helpful in improving our workflow for staff.”

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