Following a current state assessment of clinical documentation, at a Canadian multi-site quaternary academic health centre, it was concluded that lengthy, unstructured documentation was resulting in ineffective interdisciplinary communication that lacked the patient’s perspective and failed to meet accreditation and regulatory requirements as well as patient safety and best practice needs.
Post assessment the Nursing Informatics department was mandated by corporate leadership to find a solution to these issues while at the same time preparing the organization for the future electronic patient record. In order to achieve this goal the paper-based system was redesigned to better capture the organization’s patient-centred care philosophy, clinician assessments, actions and outcomes. Learn how Nursing Informatic’s facilitated and coordinated the collaboration of nurses and allied health colleagues to develop and implement Focus Charting along with an innovative acronym, PCARE, to structure clinical notes. As well discover the processes and tools used on this journey toward electronic documentation that helped engage clinicians in this organizational and practice change initiative.
Biography
Agnese Bianchi As a Project Manager, Agnese leads the clinical documentation initiative for nursing and allied health at the University Health Network, Toronto, Canada. Her responsibilities include the development and implementation of an electronic documentation system that captures and guides practice based on a patient-centred practice model and grounded on best practice and nursing sensitive patient outcomes. She also provides consultation on clinical practice, paper documentation, and policy development. Agnese participates in local and provincial committees looking at the electronic health record and nursing informatics. As well Agnese sits on the Discipline Committee at the College of Nurses of Ontario.
Heather Pollex is a Nursing Education Coordinator at the University Health Network in Toronto, Canada. In this corporate role, she acts as a resource and consultant in nursing education and professional development. She has a Doctorate in Education from OISE/University of Toronto and holds a clinical faculty appointment at McMaster University as Assistant Professor in the Faculty of Health Sciences (School of Nursing). Her areas of interest are in workplace learning, leadership development, interprofessional practice, change management, and program planning. She has presented at many local, provincial, and international conferences.