1. Burnett, Daphne MS, RN, CCNS, CNS
  2. Winningham, Marci MS, RN, CCNS, CNS
  3. Hartzell, Doug MHR, RN

Article Content


To provide clinicians with a comprehensive electronic Nursing Plan of Care (POC) for acute care patients utilizing NANDA nursing language.



Providing adequate documentation of patient care is always an ongoing struggle in any institution. Meeting Joint Commission on Accreditation of HealthCare Organizations (JCAHO) requirements is also a struggle when it comes to documentation of the POC. Integris Health in Oklahoma City has worked with the Cerner system toward providing an electronic medical record (EMR). Integris Southwest Medical Center achieved great success with the placing the Admitting Patient History form online and making pertinent fields required items in order for the history to show complete during electronic auditing. The CNSs identified the Nursing POC as an important part of the patient medical record that is not always completed by the nursing staff with their current documentation utilizing the FOCUS system. Creating an EMR Nursing POC that would compliment the pieces of medical record currently electronic would not only benefit the nursing staff but would achieve all the JCAHO requirements necessary in planning patient care.


Description of the Project

Together with the Care Net Systems manager, the CNSs worked to provide a comprehensive POC looking at each system identified within the current FOCUS documentation. The group initially met with Nursing leadership and the leadership of the ImPaCTT project at Integris Health. The ImPaCTT project oversees all of the EMR at Integris Health. During this meeting many ideas were discussed as well as what body of nursing language to utilize for the POC. After this meeting, the CNSs researched various nursing languages including NIC, NOC, and NANDA. It was then decided to utilize NANDA as the core for the nursing POC. Each Focus section currently used at Integris Health was looked at individually and nursing diagnosis, nursing goals, nursing actions, and patient responses were identified. The program was built so that an individual nursing diagnosis was identified and a goal established. As the nurse documents, he or she can identify numerous actions for each diagnosis and goal. A response is also identified as ongoing or resolved. The nurse clicks on the box next to the item selected for the patients' POC, which simplifies the computerized process for the end-user.



A pilot study utilizing a medical/surgical unit at Integris Southwest Medical Center was utilized to roll out the Nursing POC. Minimal education was required on how to fill out the form because the user had current computer knowledge with other EMRs utilized at Integris Health.



During the pilot it was recognized that a few areas in the POC were not available depending on utilization of the FOCUS sections. The main section missing related to endocrine-type disorders. Currently, the CNSs are working to add this section to the POC and will be utilizing this housewide in June of 2004.


Section Description

This year's annual NACNS conference is planned for Orlando, Fla, March 9-12, 2005. Over 300 clinical nurse specialists (CNSs) are expected to attend, and as with past conferences, attendees will also include graduate faculty from CNS programs, nurse administrators, and nurse researchers. The theme of the conference, CNS Leadership: Navigating the Healthcare Environment Toward Excellence, was selected to showcase the many ways CNSs acquire and disseminate knowledge and innovative practices in their specialty areas. Two preconference sessions are scheduled. One session, sponsored by NACNS Legislative/Regulatory Committee, targets information for CNSs interested in understanding the legislative/regulatory process as it deals with the practice of nursing, and will also help build skills CNSs need to engage in the process. The second session, sponsored by NACNS Education Committee, focuses on CNS education issues, and as with the education preconferences of past years, anticipates informative dialogue and much sharing among CNS educators around curriculum design, teaching strategies, and indicators of quality in the curriculum that link to the NACNS education standards to program review and excellence. The conference planning committee is proud and pleased to have Jeanette Ives Erickson, MS, RN, CNA, Senior Vice President for Patient Care Services and Chief Nurse Executive of Massachusetts General Hospital as the opening keynote speaker. She will begin the conference by highlighting the importance of CNS practice on patient safety. The planning committee is equally proud and pleased to have NACNS past-president Rhonda Scott, PhD, RN, Chief Nursing Officer of Grady Health System as the closing speaker. Dr Scott will challenge attendees to use the information from the conference to shape quality care delivered in a safe environment and to advance the profession of nursing through direct care to clients, influencing standards of care delivered by other nurses, and influencing the healthcare delivery system to be to support innovative, cost-effective, quality nursing care. A total of 64 abstracts for podium and poster presentations were selected in addition to graduate student posters. The abstracts address the 3 spheres of CNS practice with a strong emphasis on clinical practice improvements. As you will note from the abstracts published in this issue of the journal, specialty practice areas represented in the abstracts include children, adults, and gerontological patient groups; hospital, outpatient, and home care settings, and community health. In addition, a wide variety of specialty topics including smoking cessation programs, end-of-life care issues, and protocols outlining nursing approaches to improved diabetes, cardiovascular and ventilator management. A number of the abstracts described hospital and healthcare system level innovations that resulted from CNS practice. Collectively, these abstracts reflect the breadth, depth, and richness of CNS contributions to the well-being of individuals, families, groups, and communities. The following abstracts are from those presenters who elected to have their work published in the journal so those who are unable to attend this year's conference can share in the knowledge of the conference. As you read each abstract, consider the talent and clinical scholarship of your CNS colleagues who are advancing the practice of nursing and contributing to improved outcomes for patients and healthcare organizations. You may want to contact individual presenters to network, collaborate, consult, or share your own ideas about these topics. Watch for next year's call for abstracts and consider submitting an abstract for presentation at NACNS's next conference in Salt Lake City, Utah, March 15-18, 2006.