1. Stark, Susan MSN, RN, APRN, BC, CNS

Article Content

Statement of Problem

Our narrative documentation system lacked definitive descriptors and the ability to support the evaluation of nursing processes. The hospital also had a strategic plan to implement an EMR. Together, the opportunity existed to design a documentation framework creating a synergistic relationship between best nursing practices and computerization.



To develop documentation philosophy and structural framework based on evidence and standards of care that captures the essence of nursing practice and facilitate the transition to computerization.



In preparation for computerization, a new paper documentation system was created based on a framework of defined descriptors and protocols. The protocols and specific nursing care sets represented evidence-based nursing practice and structure for the EMR.



Key stakeholders from each nursing practice area were recruited to the documentation committee. Following an intensive literature review, including the American Nurses Association documentation and JCAHO standards, definitive descriptors were identified. Practice Council used evidence and standards of care to develop practice protocols. The CNS was positioned to facilitate the development of a documentation framework. The written system was then piloted, refined, and implemented throughout the hospital.



The act of defining best practices increased nursing ownership of patient care standards and outcomes. JCAHO recognition of the documentation system as "best practice" added validity to the product. Our protocols and descriptors are streamlining the transition to EMR for our hospital and others in our system.


Implications for Practice

Operationalization of best practice documentation facilitates outcome measurement and process improvement. This allows the CNS, and others, to evaluate the effectiveness of clinical practice.


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.