Want to simplify charting? IL hospital knows how
ICU consolidates note taking and uses road maps
Critical care nurses at OSF Saint Francis Medical Center in Peoria, IL, have simplified their system for organizing the traditional patient record with an approach that consolidates large amounts of clinical documentation into one section of the chart and thereby saves clinicians time in reading through pages of unwanted notes.
The system also uses custom-made flowcharts that help track a patient’s medical progress and record the effectiveness of treatment plans and other therapies in an easy-to-read format. The charts are stored in the patient record and are said to eliminate the need for keeping separate nursing Kardexes and related paperwork, proponents say.
An unconventional approach
The approach admittedly breaks with convention but doesn’t violate standards set by the Joint Commission on Accreditation of Healthcare Org anizations based in Oakbrook Terrace, IL, says Janis Noone, RN, MSN, a clinical practice specialist at Saint Francis who helped develop the system.
Rather than having members of different clinical departments such as X-ray or pathology chart in separate sections of each patient’s medical record, the new system involves an interdisciplinary approach:
o Progress notes.
Nurses’ and technicians’ notations from all hospital departments are entered in the same section of the progress report typically used by physicians. But each entry is set off by easy-to-read headings that identify the clinical department entering the notation so "anyone can selectively read the desired information without having to flip through several sections of the chart," Noone says.
For example, radiology simply would indicate the date and time of the entry in the left-hand margin followed by the name of the clinical department prior to beginning the narrative, she says.
o Flow sheets.
These pre-printed grid sheets are set off in columns that record the dates and times of physicians’ orders, including lab work, clinical assessments, and physical therapy. One chart captures a 24-hour period in the patient’s ICU stay and uses a series of checks to indicate that the order was fulfilled at the appropriate time.
A separate flow sheet not used in the ICU but throughout the rest of the hospital covers a three-day period and contains numerical information about changes in the patient’s condition, including vital signs, weight change, blood pressure, and body temperature. A third lists areas of the patient’s body in the left margin and dates running across column at the top. A series of checks, asterisks, and arrows signify normal, abnormal, and abnormal-but-consistent, respectively.
The system is supported throughout by an emphasis on "charting by exception," which is aimed at reducing superfluous verbiage and redundancy in note taking. Charting by exception has become popular among nurses in recent years as a remedy for writer’s cramp. It involves avoiding statements that previously were recorded in the chart or are patently true and emphasizes salient information previously unknown or unrecorded.
Finally, an additional innovation has been to keep the patient record at the patient’s bedside at all times instead of storing the chart at the nurse’s station. This keeps the record up-to-date and always available, says Noone.
(Editor’s note: To obtain samples of the flow sheets mentioned above and additional information about the consolidated progress notes, contact: Janis Noone, clinical practice specialist, OSF Saint Francis Medical Center, Peoria, IL. E-mail: [email protected])
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