Clinical Documentation Design and Implementation
Clinical Documentation Standardization
In many hospitals today, care is still documented utilizing individual unit or clinician specific methods and preferences. A range of terminology may be used to describe care and new forms proliferate, creating redundancies, making trending and quality reporting difficult, impeding smooth data flow into the EMR, and ultimately defeating the integrated capabilities of today’s leading advanced clinical systems. This lack of standardization can be the case whether the health record is still in paper, or online.
The implementation of advanced clinical systems and electronic medical records provides the best opportunity to standardize documentation and implement care planning models that utilize standardized language. This effort is vitally important to meet the intent of Meaningful Use criteria and to provide more effective and satisfactory use of the electronic health record.
We provide expert RN Clinical Informaticists who assist hospitals to:
- Assess current clinical documentation for terminology, compliance, duplication and reporting needs
- Educate on opportunities for standardization to establish a vision for outcomes that improve communication and patient care
- Assess care planning models and identify a multi-disciplinary approach that will work best for your facility
- Design systems to drive adoption of language standards such as NANDA, NMDS, and CCC for optimized care plans, assessments, flow sheets, interventions and for improved data collection
- Simplify clinician workflows that support adherence to standards of care
- Design clinical systems to leverage information integration, automated reporting and data flow to the EMR
- Streamline the build to improve ongoing IT support
- Monitor and report on quality components for both pre and post implementation
