Please carefully read all the instructions below and use the attached Prospectus Checklist and Template to complete this assignment in APA format with a minimum of 15 to 20 scholarly references less than five years old.
The facility recently transitioned to a new and better electronic health record system and also purchased standardized care plans which are supposed to be more efficient, unfortunately, the compliance with using the standardized care plans by the inpatient nurses is only 40%. Also, the facility recently had a visit of the Joint Commission and received a negative mark for the nurses not adding care plans based on the patients’ primary problem (s) or diagnosis in the patients’ charts upon admission.
Title: Educating Inpatient Nurses to use Standardized Care Plans (Based on this title, please formulate a PICO question which gear on educating the nurses to use the hospital standardized care plans)
Main Problem with the nurses in the Hospital.
(1) There’s poor compliance with the nurses not adding the standardized care plans to the patient’s chart based on the patients’ diagnosis or primary problem(s) upon admission to the facility.
(2) Nurses are not using the already built in standardized care plans in the electronic health record system of the hospital to include individualized standardized care plans to the patients’ chart based on the patients’ diagnosis or primary problem(s) upon the patients’ admission to the hospital.
(3) The hospital recently had a visit of the Joint Commission and got penalized for the nurses not adding care plans to the patients’ chart based on the patient’s diagnosis or primary problem(s) to the already built-in individualized patient care plans in the hospital electronic health record system.
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What are the benefits of adding and documenting on individualized standardize care plan in patient’s chart?
___ Set of care plans are available and nurses do not have to develop a care plan
___ If nurse selects and adds care plan, it will automatically populate into patient’s chart
___ Patient’s educational tablet is dependent on nurses’ completion of adding care plan to the
patient’s chart.
___ Decreases nurses’ workflow time because preset care plan
___Nurses do not have to do any follow up teaching on care plan
Revised PICO Question: Will an educational tool increase the inpatient nurses’ knowledge about the use of the hospital newly built-in standardized care plans system as compared to not using the standardized care plans? (based on all the above, I came up with this question, but you can correct it or formulate a better one which gears towards educating the inpatient nurses to use the standardized care plans)
Problem:
1) Poor compliance, just 40% of the hospital inpatient nurses are using the hospital newly built-in standardized care plans.
2) The Joint Commission (JHACO) penalized the hospital during a recent visit to the hospital because only a small percentage of the admitted patient had a care plan upon admission based on their diagnosis or primary problem(s).
3) The hospital recently transitioned to a new and better electronic health record system (EHRs) and some nurses are stating that they haven’t received enough education on how to use the standardized care plans on the hospital new EHRs.
Below is the Joint Commission Standard for Care Plans
Joint Commission Standard
- The medical record contains the following clinical information:
– The reason(s) for admission for care, treatment, and services
– The patient’s initial diagnosis, diagnostic impression(s), or condition(s)
– Any findings of assessments and reassessments
– Any allergies to food
– Any allergies to medications
– Any conclusions or impressions drawn from the patient’s medical history
and physical examination
– Any diagnoses or conditions established during the patient’s course of
care, treatment, and services (including complications and hospital acquired
infections).
– Any consultation reports
– Any observations relevant to care, treatment, and services
– The patient’s response to care, treatment, and services
– Any emergency care, treatment, and services provided to the patient
before his or her arrival
– Any progress notes
– All orders
– Any medications ordered or prescribed
– Any medications administered, including the strength, dose, route, date
and time of administration
– Any access site for medication, administration devices used, and rate of
administration
– Any adverse drug reactions
– Treatment goals, plan of care, and revisions to the plan of care
– Results of diagnostic and therapeutic tests and procedures
– Any medications dispensed or prescribed on discharge
– Discharge diagnosis
– Discharge plan and discharge planning
- The hospital plans the patient’s care based on needs identified by the patient assessment, reassessment, and results. The written plan of care is based on patient goals and time frames required to meet goals. Patient care plan is based on established goals where staff evaluate the patient progress Patient’s care plan is revised with goals based on patient’s needs
POPULATION: Inpatient Nurses
INTERVENTION: (Will an educational tool?) Best method on educating inpatient nurses on identifying appropriate patient’s diagnosis or primary problem upon admission to select individualized care plan and document on the interventions / progress toward patient goals each shift in Epic EHRs.
COMPARISON: Regular Care plan
OUTCOMEs:
- Patient Outcome:
- Reduced variability in patient care delivery. Accurate monitoring of progression toward evidence-based care plan interventions and goals.
- Accurate monitoring of patient education progression driven from correct diagnosis-based care plan added on admission to the patient’s chart.
- Metrics: nursing documentation on education, interventions, and care plan goals
- Process Outcome:
- Nurse will increase correct application of evidence-based care plan based on identification of correct diagnosis or primary problem upon admission Increase documentation of evidence-based interventions and patient progress toward care plan goals in EPIC each shift. .
- Increase completion of education/learning assessment upon admission and each shift.
- Metrics’ compliance: correct application of care plan based on admitting diagnosis, shift documentation of evidence-based interventions and care plan goals, patient education/learning assessment documentation
