Abstract 2583: Customizing the Electronic Medical Record to Achieve Excellence in Nursing Documentation of Stroke Care Indicators in the Emergency Department at Kenmore Mercy Hospital
Background: Chart review demonstrated inconsistencies in the documentation of specific areas of Emergency Department Nursing stroke care indicators. These inconsistencies included the Dysphagia Screen and the documentation of time of Code Stroke called. At the time of this discovery in 2008, the patient chart was a hybrid of a paper and an electronic record. This resulted in the potential for data being captured in multiple areas of the chart, and was identified as a patient safety risk.
Increase compliance in Emergency Room nursing documentation
Create clear and consistent stroke patient record via universal format
Enhance the ease of use of patient record by eliminating the hybrid system in the ED
Ensure reliable communication among all clinicians caring for the patient
Retrospective and concurrent review of charts to determine most common opportunities for improvement
Identify staff barriers to compliance, i.e. lack of standardized format to document care, and the reluctance to return to paper charting once the electronic record was efficiently utilized
Create a mandatory “Time Code Stroke Called” and “Dysphagia Screen” pathway in the electronic medical for triaged patients vs. free text/paper Code Stroke log documentation
Re-review charts after implementation and provide staff education of the standardized format
Increase in Dysphagia Screen compliance from 45.6% in 2008, to69.9% in2009, to83% in2010
Reliable documentation of “Code Stroke Called” is found in every record
Lesson Learned: creating simple documentation for clinicians increases compliance in capturing the required elements of stroke care
Conclusions: Customizing electronic medical records to eliminate hybrid charting has increased nursing documentation compliance of the Dysphagia Screen and the time of Code Stroke called in Emergency Department stroke patients at Kenmore Mercy Hospital.
- © 2012 by American Heart Association, Inc.