“Electronic Charting: The ‘Spring’ of a New Documentation Era”

Steve Biondi, M.S., RNWendy Ehnis, M.S.N., RN

Rita Roedel, M.S., RN

Extendicare Health Services, Inc.

Spring Thoughts

• In like a Lion out like a Lamb

• Spring Forward

• Spring Training

• Spring Fever

Focal Areas

• Why• Pilot Experience• Front Line Staff Characteristics• Documentation Elements• System Design• Operational Considerations• Teaching Strategies• Outcomes

Background

Why• Wanted to improve resident care

– Real time documentation– Up to the minute compliance monitoring– Standardization of charting– Eliminate illegible handwriting

• Wanted to improve manual system– Incomplete– Labor intensive– Data analysis was difficult– Trending was cumbersome

• People at all organizational levels had positive experience with electronic CNA charting system

Background

Outcomes

• Easy to learn

• Flexible as documentation parameters change

• Easy to use

Background

Pilot• Facility proven track record

– Stable Administrator, DON, MDS Coordinator– Good survey history– Supportive of corporate systems– Adapts well to change

• Five geographically diverse locations began in April 2006

• Four basic clinical parameters chosen• Within 6 months decided to implement corporate

wide

“The worlds favorite season is the spring. All things seem

possible.”

--Edwin Way Teale

Front Line Staff

Characteristics• Visual Learners

– Bright colors– Visual Cues– Emphasize key concepts

• Native Language– Workforce diversity

• Reading Skills– Simple terms– Reinforce with graphics

Front Line Staff

As Adult Learners

• Need to see value of system

• Need to see practicality of system

• Need to be shown respect for prior life and work experiences

Documentation Elements

Why Chosen• Based on elements most frequently charted

by CNAs• Encompass some of more prominent QI/QM

and RUG elements that are critical to the resident POC

Documentation

Implementation Elements

Section RUG QI/QM

E 21 27

G 7 17

H 2 4

K 5 4

35 (32%) 52

Documentation

Elements• Mood (E)

– 16 elements– Frequency

Up to 5 days 6 to 7 days

• Behavior (E)– 6 elements– Frequency

1 to 3 days 4 to 6 days Daily

Documentation

Elements

• Mood (E)/Behavior (E)

–Consider alterabilitySystem tracks interventions triedEffectiveness of interventions

Documentation

Elements• ADLs (G)

– 11 Elements– Self performance and support provided– Focus “late loss” because of RUG and QI/QM

implications Bed mobility Transfer Eating Toilet Use

Documentation

Elements• Continence (H)

– Bowel/Bladder– Self control categories– Scheduled toileting– Bladder retraining

Documentation

Elements• Weight Loss (K)

– 5% 30 days– 10% 180 days– System has flexibility for percentages and time

parameters

• Nutritional Approaches (K)– Considers IV, tube feeding– Tracking of food and fluid intake

Documentation

Elements Added• Restorative Nursing (P)

– Number of minutes/24 hours– Number of days > 15 minutes/24 hours

• Staff consistently communicate they want documentation on elements added!!

“An optimist is the human personification of spring.”

--Susan J. Bissonette

Documentation System

Design• Easy to learn

– Must be able to de-”CMSize” language (i.e. support provided of 1 person coded 2 on MDS)

– Get up to speed quickly• Visual

– Images/graphics reinforce key concepts• Basic reading skills

– Target was 6th – 8th grade level• Time sensitive

– Entries date/time stamped– Prohibit charting until logical (i.e.

unable to document lunch consumption until time appropriate)

Documentation System

Design (cont.)• Independent

– Avoid “copy cat” charting

• Staff working smarter– “Chart as you go”– Alerts staff to situations requiring attention

No bm in last 9 shifts Less than 1000 cc fluid intake over 24 hours

• Acknowledge job well done– Real time feedback– Able to pinpoint shift, location, individual employee

performance

Operational Considerations

Security access• Based on function at building

– CNA kiosk for data entry– Licensed staff care alert reports

• HIPAA compliance– Used unique resident demographic information– Reinforced confidentiality @ kiosks

• System backup– Nightly back-up at off-site date center

• Home like environment– Aquarium screen saver

“Spring is when you feel like whistling even with a shoe full

of slush.”

-- Doug Larson

Flexible Teaching Strategies

• Classroom– Initial rollout training– Short session

• One – to – One– Kiosk for data entry– Work station for report overviews– Used tell-show-do approach

• Chewable bits– ADL and Mood/Behavior coding week before– Education Resource Binder

• Mood/Behavior Bingo• ADL cards describing scenario

– Real time resident function/behavior

Flexible Teaching Strategies (cont.)

• Visual Aids– Quick reference laminates at Kiosks– Story boards– System has additional help screens

• Key Points– 75% adults retain more information from sight

education than other senses– 72 hours is key for retention of learning

• Went live within 24 hours

Outcomes• Completeness of documentation

– Corporate standard > 95%– Consider

• 100 documentation elements• 100 bed SNF• 10,000 documentation elements/24 hours @ 95 compliance is 9500

• Monitor resident status– Care alert reports

• Enhanced communication– Messaging feature

• Catch staff doing it right– Individual staff, shift, unit

• Capture resident acuity– Fewer “holes”– Multiple entries

• Fire story

Spring is natures way of saying “Let’s Party!”

--Robin Williams