Speaker
Description
Introduction.Clinical records are documents containing data, assessments and others informations about a patient's clinical status during the health care process. In most Spanish healthcare organizations, the Electronic Health Records(EHR) has been introduced as a way to facilitate transportability of pertinent information concerning patient’s illness across varied health providers. So, EHR are a patient's right and a professional's duty in order to guarantee adequate healthcare. These records can serve as a guide for professionals to unify and systematize diagnoses and interventions, promoting equality in care and equity in health outcomes. The implementation of RNAO Best Practice Guidelines(BPG) implies improvements in care processes that must be reflected in the EHR.
Objective:To integrate the registration of RNAO BPG recommendations in a standardized way into the EHR of the Castilla-La Mancha(CLM) Health Service (SESCAM).
Main points:Work groups led by nurses with expertise in implementation and evaluation were formed to propose modifications to the EHR, coordinated by the BPSO-CLM regional Host.
Outcomes and results: 23 forms and standardized care interventions have been modified in the hospital setting and 12 in primary care. Forms are related to assessment of pain, breastfeeding, pressure ulcers risk, neurological status in patients with stroke, dysphagia or wound healing. The standardized care interventions are applied to patients at risk of falls, pressure ulcers, stroke, breastfeeding, pain or ostomies. Client satisfaction with the process is 85.7%. The restructuring of the EHR, including a common base of standardized forms and interventions on the application of RNAO BPGs, contributes to avoiding unwanted variability in patient care and promotes equal care for patients in any SESCAM healthcare centers.
Benefits to symposium participants:This experience demonstrates the feasibility and effectiveness of standardizing nursing records based on RNAO BPGs to promote equality of care. These outcomes suggest that standardized nursing records can contribute to reduced healthcare disparities.
Keywords
Nursing records, electronic health records, best practice guidelines, standardization, equality of care
What RNAO BPG or tool/toolkit is this work related to:
Leading change toolkit
Author(s) Credentials and Title
RN, MSc, PhD studient
| Organization Name | Castilla-La Mancha Health Service (SESCAM) (Spain) |
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