Designing Assessment Flow Sheets for Charting by Exception

Milwaukee, WisconsinApril 30 – May 2, 2007

The Presenters!• Penny Hunt, RN, MHSA

• Senior Application Analyst• St. Rita’s Medical Center – 36 years• 19 years Psychiatric Nursing• 15 years Information Systems:

Cerner, EXCELCARE, ANSOS

• Annette Meyer, RN• Clinical Application Analyst• St. Rita’s Medical Center – 41 years• 35 years – Clinical (Med/Surg) experience• 6 years Information Systems – Cerner applications

Where is St. Rita’s Medical Center?

L ost

I n

M iddle

A merica!

Ohio

Since 1918, St. Rita's Medical Center has been providing quality healthcare to the people of West Central Ohio.

Founded by the Sisters of Mercy, St. Rita's is now part of Catholic Healthcare Partners (CHP).

Nursing Units/Specialty Areas# of

Beds

Med/Surgical Units 166

ICU / CCU 22

Open Heart 13

Pediatrics 16

Behavioral Services: Adult, Geri-Psych, Addiction Services 53

Transitional Care (SNU) 18

Rehab Unit 20

Obstetrics 22

Newborn Nursery 44

Total Beds 374

Total Licensed Beds 425

Medical Center of the Future!

Presentation Objectives:

• Describe the baseline admission data elements necessary to perform ongoing assessments

At the conclusion of this presentation, we hope that you will able to:

• Verbalize understanding of the concepts used in the design of the assessment flow sheets

And so the story begins…..

Once upon a time, in the summer of 1996, a creative, interdisciplinary team met to redesign documentation.

The Project Team worked with consultants from Ernst and Young. Their methodology enabled the team to determine the:

– Current State of Documentation

– Future State – Vision of the Ideal Documentation Process

Project Team Mission:

The Clinical Documentation Redesign Model

• Document the flow of patient care from admission to discharge

• Identify documentation points throughout the patient care process

Evaluation of Current State Documentation

• Identify and categorize current chart forms

• Assess forms: Keep, Modify, Merge, or Delete

• Consolidate Forms/Develop New Forms

• Plan, Educate and Pilot the new forms and processes

What did they find?

• Lots of forms

• Redundant charting

• Pages of narrative notes

• Some flow sheets – some used, some not

• Forms being illegally created - renegade forms!

• Storage of forms everywhere

Opportunities for Change • Streamline documentation (through use of flow sheets)• Adopt an interdisciplinary focus (Interdisciplinary

Progress Notes)• Create Flow Sheets and adopt Charting by Exception as

the model for system review documentation• Increase accessibility (Wall-a-Roos for point of care

documentation)• Reduce redundancy and duplication (“one stop

shopping”) • Create forms that are adaptable to electronic production

and computerization• Decrease storage space required for forms

Transition Forms – Shift to Computerized Charting

• Patient Data Base/Admission Assessment – used by ED, Pre-admission, Inpatient Units

• Patient Care Flow Sheet – used by Medical/Surgical and Step Down Critical Care Nursing Units

Patient Data Base/Admission Assessment Form

Concepts:

• Collection of data begins wherever the patient enters the continuum of care (ED, Pre-admission, Inpatient Unit)

• “Write once – read many” (quit asking patient same questions at each point of care)

Patient Care Flow Sheet

One form for the documentation of:• ADL’s (Hygiene, Safety, Activity/Mobility)

• Interventions – Reflect the Plan of Care• System Review – Charting by Exception• Focused Sections for Pain, Skin, and

Nutrition Documentation• Nursing Narrative Notes using Focus

Charting Model of Documentation

Patient Care Flow Sheet Concepts:

• Charting by Exception was the model of documentation used for System Review after the Baseline Assessment was documented.

• Chronic Conditions from the assessment were noted under each system to “individualize” the form to the patient.

• Normal parameters were defined for each system and printed on the form to assist the nurse to determine if the patient was Within Normal Limits or not.

Patient Care Flow Sheet Concepts, cont.

• Patient assessment would be documented every 4 hours or more often as needed.

• Only abnormal symptoms were documented for the specific system.

• Nurse determined at each assessment if the patient was:– Within Normal Limits– Continuing with same abnormal symptoms as

previously charted– Displaying a new abnormal symptom, or,– Moving towards a normal state for him.

Patient Care Flow Sheets: Roll out to other areas

• Pediatrics

• Behavioral Services

• Rehab and Transitional Care

• Same Day Surgery

Same concepts with consistency in design

http://www.ehealthconnection.com/regions/

http://www.ehealthconnection.com/regions/

Chronic Conditions

Then…10 years later! Electronic charting in PowerChart

Same concepts prevail:• Capture data in one place – read by many• Determine a representative core of diseases that

could significantly impact the ongoing assessment of patient

• Document full baseline assessment of patient at admission

• Determine the “systems of concern” post baseline assessment

Charting by Exception - Defined

• At St. Rita’s Medical Center, the “normal” conditions for the patient are recognized and noted on admission, and taken into consideration when continuing the ongoing assessment process.

• The normal parameters for each body system have been standardized and acceptable normal limits defined.

• This information displays beginning with the ongoing assessment after the baseline assessment has been determined.

Patient History – Chronic Conditions

Information pulls from one encounter to the next. Nurse verifies information at each admission/encounter.

Baseline Physical Assessment - Cardiovascular

Baseline Physical Assessment – Respiratory

Ongoing Assessment: System Review Section

From the Patient/Family History

Instructions to the nurse:When you assess the patient each time, you will review the “normal parameters”, the patient’s chronic conditions, the previous charted results, AND together with your own current assessment, decide if the patient is WDL, changed or unchanged.

Assessment Changed or Unchanged: What happens?

Clicking the Unchanged box will chart all the values on this section. The nurse must agree with this “previous” assessment, or choose Changed from screen before and add/replace values per current assessment.

Flow Sheet View

Previous Charted Assessment Review:

System Review for the Outpatient

• Establish “predictable normals”

• More problem focused assessment

• Default normals for the population

• Customize to the outpatient, “normal” type of patient

System Review for OB Patient

System Review – Outpatient Oncology

Charting Abnormal Values: System Section Opens

Thank you for attending!

If we can be of any further help, please email us at:•Penny Hunt:

plhunt@health-partners.org•Annette Meyer:

ammeyer@health-partners.org