Marie S.W Wells, MS, RN, CNOR: No financial relationships to disclose
Description: This abstract demonstrates the actualization of the Information Management Guideline in practice.
Effective nursing care plan documentation is essential for ensuring quality and safety in patient care. Compliance with documentation standards remains a persistent challenge for the Operating Room nurses because of the current design which is outdated and doesn’t align with the current AORN care plan standards. The existing build does not follow the normal nursing care plan workflow and is not customized to facilitate completion. AORN’s guideline on Information Management highlights the importance of using a multidisciplinary team to edit and customize all information management systems and designing systems to provide for clear representation of the patient experience. This project involved a multidisciplinary partnership between Industry partners (AORN Syntegrity team), Regulatory leadership, nursing staff, the informatics and clinical education teams working to address gaps in nursing care plan documentation in the Intra-operative phase of care. Analysis of current staff compliance and the workflow within the electronic health record (EHR) identified significant areas for improvement. This initiative aimed to align the EHR to better reflect the nursing care plan process and to simplify the documentation workflow for the nursing staff, making it more user friendly. Initial compliance data was collected which confirmed a major deficit in accurate documentation of the care plan. The team is actively working to optimize the documentation process, and once modifications are complete, staff re-education will occur. Data collection will be done post go live to benchmark improvements in documentation compliance. The primary goal is that there will be a significant improvement in both compliance rates and accuracy of documentation, resulting in improved alignment with regulatory standards. This initiative highlights the benefit of partnerships between clinical end users and informatics teams to drive sustainable improvements in clinical do improvements in clinical documentation processes.
