Documentation Question: CBE & Care Planning

[rmccoy27]

our hospital is in the process of selecting a new clinical system, and i have a couple of broad questions for the community.

we currently use online charting via templates for most of our nursing assessments. with the use of templates, the amount of "data" collected is voluminous, and begins to sound like a parrot reading back a script. it is very difficult to hear the patient's story from all the "canned" text associated with templates. with the opportunity of a new installation, we are hoping to improve documentation by requiring less "clicks" on unnecessary information, and the capture/synthesis of more "information" that tells the story of the patient.

how are hospitals meeting this challenge with online documentation?

is charting by exception an accepted method that facilities have adopted with online systems?

how about the plan of care? i would be interested in hearing back from facilities if they are sticking with the traditional nursing "care plan" with nanda diagnoses and interventions/outcomes (perhaps nic and noc), or are care pathways more intuitive for interdisciplinary care? or are there other solutions out there that are working for your nurses.

[rninformatics, DNP, RN]

greetings rmccoy27,

our facility indorses documentation by exception within the emr/clin doc systems.

related to our care plans - the nursing care plan was originally (5+ yrs ago) using nic,noc and nanda but has since been revised using more interdisciplinary accepted language.

hope that helps!

our hospital is in the process of selecting a new clinical system, and i have a couple of broad questions for the community.

we currently use online charting via templates for most of our nursing assessments. with the use of templates, the amount of "data" collected is voluminous, and begins to sound like a parrot reading back a script. it is very difficult to hear the patient's story from all the "canned" text associated with templates. with the opportunity of a new installation, we are hoping to improve documentation by requiring less "clicks" on unnecessary information, and the capture/synthesis of more "information" that tells the story of the patient.

how are hospitals meeting this challenge with online documentation?

is charting by exception an accepted method that facilities have adopted with online systems?

how about the plan of care? i would be interested in hearing back from facilities if they are sticking with the traditional nursing "care plan" with nanda diagnoses and interventions/outcomes (perhaps nic and noc), or are care pathways more intuitive for interdisciplinary care? or are there other solutions out there that are working for your nurses.