Background and Significance:

Nurses need to document the contribution they make to patient outcomes. Within the Department of Veterans Affairs, documentation tools and practices vary from facility to facility. With a lack of standardized data definitions, assessment instruments, and/or methodology for documenting assessments, there is no ability to retrieve or compare clinical indicator data nationally.

Specific Aims:

The Office of Nursing Services approached this dilemma by supporting the development of standardized nursing documentation templates for the electronic health record to be implemented across the system. These templates would allow for automated extraction of identified data elements, resulting in data retrieval efficiency and effectiveness and facilitation of data analysis.

Methods:

Thirty-eight nurses representing all levels of nursing practice determined content based on Joint Commission requirements, Veterans Health Administration directives and policies/procedures, and evidence-based practice. Other professional healthcare disciplines contributed to the templates in relation to their specialty (eg, nutrition, social work, chaplaincy). Interdisciplinary work groups were convened to create a nationally standardized clinical terminology catalog and an interdisciplinary approach to care planning.

Outcomes:

Twenty-five pilot sites have provided feedback on the flow and functionality of the templates. Local "site coordinators" will oversee the phased-in implementation of the templates at their facilities.

Lessons Learned:

This presentation will focus on the process, the interdisciplinary approach, the barriers, and the challenges associated with template development. It will also address the approaches taken to help create a bridge (versus a barrier) to safe, evidence-based, personalized care for veterans.

Section Description

We are pleased to share the paper presentation abstracts from the Summer Institute in Nursing Informatics, Informatics at the Point of Care: A Barrier or a Bridge?, held at the University of Maryland School of Nursing, July 22 to 25, 2009. The program, chaired by Dr Judy Ozbolt, was a great success. Each of the following abstracts was selected for presentation by a peer-review committee.