Inpatient Care Plans/Education documentation working well?

[Ativan]

We need to streamline and improve compliance with documentation on care plans & patient education at my hospital. Does anyone working inpatient think their system of documenting on Care Plans & Patient Education is working well? As in: nurses don't absolutely HATE it, it's not too confusing or overly-complicated, the compliance rate of nurses documenting is pretty high?

What system do you use? Anyone have examples of interventions that were used in their hospital to streamline or improve the process?

[classicdame, MSN, EdD]

We have HMS documentation program. Once history and assessment is done the program automatically creates a care plan. Nurse has to review and has option to make changes. Nurses like it better than they like CPOE (computer physician order entry). MD's are resisting change and this creates more work for nurse

[HouTx, BSN, MSN, EdD]

Meditech - not the greatest.

Plan of care documentation is pretty well integrated into the system.. required fields & tons of flags and reminders.

We have integrated EBSCOs (Nursing Resource Center) patient education materials into the system. Educational materials are all from their (CINAHL-based) database; updated continuously and available in multiple languages. The interface tracks education materials provided to the patient and family... the discharge record include patient acknowledgement of the materials and understanding of key points. It was cumbersome at first, but improvements were made and it's OK now.

[classicdame, MSN, EdD]

HouTx: I like the idea of having education links! I just reminded a group of new grads this morning that decision by consensus is not appropriate (asking co-workers).

[jadelpn, LPN, EMT-B]

There are EMR's that generate both a care plan (or sometimes it is called a "problem list") as well as patient education.

The best advice I can give is to make sure you know everything you need to regarding the EMR, and how to generate these things.There is a LOT of clicking boxes, but there are other areas of the EMR that you need to update. Find out what those are, so you are touching on every part of the EMR you need to.

Some automatically generate, (mostly care plans) and some you need to choose what you need based on diagnosis (education). There are also "activity" lists, of things that the nurse needs to do. It is its own language, and if you can get to a routine of how you document, that is a lot easier, in my opinion.

With a "meaningful use" requirement, the only way for facilities to prove it, and to get money from the government for it, is to use it--a nurse's name comes up beside the category in the EMR.

IF you are on paper documentation, then you need to streamline and set policy. Get a committee together, generate some care plans that will be used, generate some info/fact sheets for education, and a reminder that the nurse needs to have "x" care plans, that with daily assessment they need to be updated, and education is given once in the course of the stay, and re-educated at discharge. There should be a "patient educated on xyz. Demonstrated back, patient verbalizes understanding of pdq"

And make sure the patient gets the written education, make sure that they know what to do and how to do it, make sure that they know what to do if their condition changes, and when they need to follow up. All should be documented on discharge.

Make sure it becomes part of a nurse's routine of documentation.

[Ativan]

Thanks everyone for your feedback! Integrated into the regular documentation and automatically generated care plans seem like the way to go! Our system (Epic) requires the RN to remember to go to a completely separate module to document care plans and another one for patient education, and it often doesn't get done. It also requires a lot of extra documentation for the RN that could just be done in the flowsheets.