Designing Assessment Flow Sheets for Charting by Exception

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Designing Assessment Flow Sheets for Charting by
Exception

• Milwaukee, Wisconsin
• April 30 May 2, 2007

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The Presenters!

• Penny Hunt, RN, MHSA
• Senior Application Analyst
• St. Ritas Medical Center 36 years
• 19 years Psychiatric Nursing
• 15 years Information Systems
• Cerner, EXCELCARE, ANSOS
• Annette Meyer, RN
• Clinical Application Analyst
• St. Ritas Medical Center 41 years
• 35 years Clinical (Med/Surg) experience
• 6 years Information Systems Cerner applications

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Where is St. Ritas Medical Center?

• L ost
• I n
• M iddle
• A merica!
• Ohio

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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).
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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
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Medical Center of the Future!
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Presentation Objectives
At the conclusion of this presentation, we hope
that you will able to

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

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

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And so the story begins..
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• Once upon a time, in the summer of 1996, a
  creative, interdisciplinary team met to redesign
  documentation.

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Project Team Mission

• 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

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The Clinical Documentation Redesign Model

• Document the flow of patient care from admission
  to discharge
• Identify documentation points throughout the
  patient care process

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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

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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

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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

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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

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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)

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Patient Care Flow Sheet

• One form for the documentation of
• ADLs (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

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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.

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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.

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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

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Chronic Conditions
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Then10 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

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Charting by Exception - Defined

• At St. Ritas 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.

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Patient History Chronic Conditions
Information pulls from one encounter to the next.
Nurse verifies information at each
admission/encounter.
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Baseline Physical Assessment - Cardiovascular
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Baseline Physical Assessment Respiratory
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Ongoing Assessment System Review Section
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Instructions to the nurseWhen you assess the
patient each time, you will review the normal
parameters, the patients chronic conditions,
the previous charted results, AND together with
your own current assessment, decide if the
patient is WDL, changed or unchanged.
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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.
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Flow Sheet View
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Previous Charted Assessment Review
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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

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System Review for OB Patient
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System Review Outpatient Oncology
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Charting Abnormal Values System Section
Opens
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Thank you for attending!

• If we can be of any further help, please email us
  at
• Penny Hunt
• plhunt_at_health-partners.org
• Annette Meyer
• ammeyer_at_health-partners.org