implementation of standardized nomenclature in the electronic medical record

Implementation of Standardized Nomenclature inthe Electronic Medical Recordijnt_1132 169..180

Joan Klehr, RNC MPH, Jennifer Hafner, RN, BSN, PCCN, TNCC, Leah Mylrea Spelz, RNC, BSN, ACCE,Sara Steen, RN, BSN, TNCC, and Kathy Weaver, RNC, BSN

PURPOSE. To describe a customized electronicmedical record documentation system whichprovides an electronic health record, Epic, whichwas implemented in December 2006 usingstandardized taxonomies for nursingdocumentation.DATA SOURCES. Descriptive data is providedregarding the development, implementation, andevaluation processes for the electronic medicalrecord system. Nurses used standardizednursing nomenclature including NANDA-Idiagnoses, Nursing Interventions Classification,and Nursing Outcomes Classification in ameasurable and user-friendly format using thecare plan activity.CONCLUSIONS AND IMPLICATIONS. Key factorsin the success of the project included closecollaboration among staff nurses andinformation technology staff, ongoing supportand encouragement from the vice president/chiefnursing officer, the ready availability of expertresources, and nursing ownership of the project.Use of this evidence-based documentationenhanced institutional leadership in clinicaldocumentation.Search terms: Care plan, electronic medicalrecord, Epic, NANDA-I, NIC, NOC, nursingtaxonomy, standardized nomenclature

Joan Klehr, RNC, MPH, is an information systemsanalyst; Jennifer Hafner, RN, BSN, PCCN, TNCC, andSara Steen RN, BSN, TNCC are staff nurses at theMedical/Surgical Intensive Care Unit; and Leah MylreaSpelz RNC, BSN, ACCE, and Kathy Weaver RNC, BSN,are staff nurses at the New Beginnings Birthing Center, ofAspirus Wausau Hospital, Wausau, Wisconsin

Aspirus Wausau Hospital installed Epic as the newclinical information system (electronic medical record)in December 2003. Epic is a nationally recognized elec-tronic medical record vendor for both inpatient andoutpatient documentation. It replaced the old legacysystem and provided electronic documentation ofclinical information, including care planning, for theorganization.

The care plan activity provided by Epic is master filedriven and requires standardization of language fornursing care plans. The staff was no longer able tocreate problems, goals (expected outcomes), and inter-ventions by entering free text data. However, therecords do include a free text description field where auser can individualize the care plan based on apatient’s particular needs or status.

A decision was required regarding whether clinicalexperts and system administrators would worktogether to create organization-specific problems,goals, and interventions, or the organization couldpursue the use of a third party product such as SnomedCT, NANDA-I, Nursing Outcome Classifications(NOC), or Nursing Intervention Classifications (NIC).Refer to Figure 1 for a schematic of the Epic care planmaster file layout.

A literature review was completed and it wasdecided that a third party product would be pur-chased. A presentation was made to the Nursing Pro-fessional Practice Committee with a recommendationto pursue the use of Snomed CT because it providednursing terminology and terminology used by otherdisciplines such as psychiatry, therapy departments,and others.

International Journal ofNursing Terminologies and Classifications

doi: 10.1111/j.1744-618X.2009.01132.x

International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 169

There was an almost immediate roadblock with theuse of Snomed CT at the time Aspirus was ready tocomplete the implementation. Snomed CT was notavailable in an electronic format and could not beimported into Epic’s master files. Because of this, theorganization proceeded to procure contract and licenseagreements to use NIC, NOC, and NANDA-I for thecare plan master files. These nursing terms would beused for other disciplines where appropriate. Epicsystem administrators then handbuilt any problems,

goals, or interventions that did not fit with the availablenursing terminology. There was also an issue with non-nursing disciplines feeling that they were being“Forced” to use nursing language for their specialties.

Once the decision had been made to pursue the useof NIC, NOC, and NANDA-I, the actual designing andbuilding of the care plans were begun. The design teamdetermined that staff would use pre-built care plantemplates wherever possible. A care plan templateconsists of a set of related problems, goals, and

Figure 1. Epic Care Plan Masterfile Schematic. NIC, Nursing Interventions Classification; NOC, NursingOutcomes Classification

Implementation of Standardized Nomenclature in the Electronic Medical Record

170 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009

interventions. Epic’s care plan product does allow formanual creation of care plan problems at the bedside.However, users must use the problems imported intothe master file records, and the creation of those careplans is a somewhat laborious task. There would alsobe no method of assuring that the care plans built inthe moment were created using the new design format.A paper template was developed to assist clinicalsubject matter experts (SME, staff nurses) design thetemplates using the correct format. They were invitedto join together to develop care plans for their specialtyareas. Textbook resources were made available to assistwith the design of the templates including the currentversions of NANDA-I (NANDA-I, 2003), and theNursing Diagnoses, Outcomes, & Interventions:NANDA-I, NOC, and NIC Linkages (Johnson et al.,2001). NOC Second Edition (Moorhead, Johnson, &Maas, 2004) and NIC Third Edition (McCloskey Doch-terman & Bulechek, 2004) were available in the medicallibrary; however, they were not given to the units toassist in the build.

Design decisions were required, as the Epic careplan format did not readily adapt to the NOC ratingscales or inclusion of the NIC activities. A recommen-dation was made and accepted to use only the NIClabels for the care plan interventions. NOC labels wereentered as the care plan goal; however, the rating

scales were not included. Epic includes a detailed fieldthat users can free text for information. The SMEscreated measurable goal statements for each NOC labelcreated. Refer to Figure 2 for an example of the careplan design.

Issues with the Initial Care Plan Build (2003)

There were several key issues with the care planproject. The biggest issue was related to knowledgedeficit regarding the use of standardized nomencla-ture. The vast majority of the nursing staff had neverbeen exposed to NANDA-I, NIC, or NOC. The averageage of nurses at the hospital is 41. Many of them com-pleted their nursing education in the 1970s and 1980s.The training programs did not include exposure tostandardized terminology as they were not readilyavailable when those nurses completed their corenursing programs. Although staff was trained in thefunctionality of Epic, the foundations of the standard-ized nomenclature were not emphasized in the train-ing. Refer to Appendix A for one department’sperspective of the change.

The NOC labels were not being used as designedwhen the Epic care plans were first implemented.NOC rating scales were not included in the build, par-tially because the program did not have a field to

Figure 2. Care Plan Design December 2003


accommodate the rating scale, but largely due to lack ofunderstanding as to how the rating scales worked. Theteam was concerned that accrediting bodies would notfind a Likert scale measurable.

Feedback indicated that the organization imple-mented too much change too quickly. The care planbuild was an entirely new workflow for many of theprofessional clinical staff. Many were not accustomedto working with computers. Asking them to use a com-puter to complete their care plans in addition to learn-ing new taxonomies was therefore overwhelming.

Practice was not monitored after the new productwas implemented; therefore, nurses and other profes-sionals were not provided with timely feedback. Thislack of feedback prevented improvement of careplan documentation and correction of problematichabits.

The method used to name the care plan templatesbecame a barrier to use. The care plan templates werenamed with a prefix consisting of the department fromwhich the template originated or where the patientpopulation was normally housed. This was done toassist users in finding the templates for their patientpopulations more easily. Practitioners mistook this as arestriction as to which care plans they could use eventhough the care plans were very appropriate for theirpatients. Instead, staff created new hand written careplans.

Practice Council Re-evaluation of Usage ofNANDA-I, NIC, and NOC

In late 2004, Aspirus hired a firm to perform a mocksurvey of the facility to prepare for a Joint Commissionsurvey visit. One finding reported that care plan goalswere not measurable and did not include definite timeframes. They were standardized with little individual-ization and were not reflective of revisions as the resultof changes in patient needs. The Hospital-Wide Prac-tice Council created a preliminary task force and rep-resentatives from each unit went to a care planningrefresher course.

The attendees of the refresher course were to dis-seminate the information to the rest of the staff. Thelack of compliance with care planning documentationcontinued. The Hospital-Wide Practice Council contin-ued to focus on care planning from 2005 to 2006. Thecouncil wanted to develop nomenclature and care plantemplates that would be consistently used by nursingstaff.

A staff nurse performed a literature review in fall2005 to identify the most appropriate nursing nomen-clature for Aspirus. She determined that the most com-prehensive and widely used nomenclatures wereNANDA-I, NIC, and NOC. Based on this, the Hospital-Wide Practice Council chartered another task force toreview the languages, revise the templates, and createnew care plans.

Team Created

The Care Plan Task Force was created in November2005. The task force was charged to review, update, andimprove the care plan documentation process atAspirus. Volunteers for the committee consistedmostly of staff nurses who had an interest in the careplanning process. The task force also included twoclinical nurse specialists who had experience withNANDA-I, NIC, and NOC, a staff member from theInformation Technology (IT) department, a staffmember from the Educational Services department,and two members from the Hospital-Wide EducationCouncil.

Early Plans

The initial task force meeting was held on Novem-ber 2, 2005. The first step was to identify problemswith the care plans and familiarize members withNANDA-I, NOC, and NIC. The next steps consistedof identifying the most frequent patient admissiondiagnoses in this hospital, evaluating the care plandocumentation, and assessing the care planningneeds. The electronic care planning system was not



complete, the templates were outdated and were notbeing used correctly by staff due lack of education,and there was general non-compliance. Many newcare plans were needed to modernize the documenta-tion. The task force recognized the importance of staffeducation as illustrated by inconsistent care plandocumentation and the incorrect use of the standard-ized nomenclature since the inception of the electroniccare plan at Aspirus. The vice president/chief nursingofficer joined in the efforts to redesign the entireprocess, and continues to do so.

Bringing in the Experts

A member of the care plan task force attended BellinCollege of Nursing in Green Bay, WI, which was one ofthe first nursing schools to incorporate NANDA-I,NIC, and NOC into their curriculum. A faculty person,a nationally known expert in the NANDA-I, NIC, andNOC standardized nomenclature, was consulted towork with the project. The task was to assist withreviewing and revising the current care plans and newones that were to be developed by the nursing staff.She recruited a colleague, the president-elect ofNANDA-I who has a degree in nursing informatics,who provided consultation to assist with the imple-mentation of the new care plans into Epic. She assistedthe team in developing a method to incorporate theNOC Likert scales into the build. An introductorymeeting was held at which time the consultants made arecommendation that several members of the projectteam attend the 2006 NANDA-I, NIC, NOC Confer-ence in Philadelphia, PA.

The theme of the conference was Electronic Use ofClinical Nursing Data. Three members of the projectteam were provided with approval to attend. The 3-dayconference allowed for an in-depth immersion into theworld of NANDA-I, NIC, and NOC. Conference ses-sions included general sessions covering topics such aseconomic evaluations of the use of standardized termi-nology, future horizons for NANDA-I, NIC, and NOC,and smaller breakout sessions which focused on

implementation projects that used standardizednomenclature including academic centers as well ashealthcare settings from outside of the United States.The knowledge and networking gained from the con-ference were utilized in the design of the new care planbuild.

Funding the Project

Funds were originally unavailable for the smallproject that would turn out to be an enormous,ongoing process. The Vice President, Chief NursingOfficer provided financial and organizational supportto the taskforce. In addition to sending members to theconference in Philadelphia and hiring the consultants,new resources were purchased and a workshop wasplanned.

Working with Epic

The IT staff and members of the task force metwith the consultant to devise a format for displayingthe care plan goal details in Epic prior to the work-shop. Adaptations were made to the care plan activityin Epic to create a user-friendly format for editing andindividualizing the outcomes. The templates weredesigned to allow retrieval of data for reporting pur-poses and any future research which may be com-pleted using the care plan. The detail fields used toadd the NOC indicator and rating scale informationwere not “discrete data fields.” A discrete data fieldhas coded values. In lieu of entering “free text” infor-mation, a nurse chooses from a list of data elements,i.e., an item from a pre-built list. A workaround forthis was accomplished by use of Epic’s discrete“smart list” functionality. Use of these records allowsdata to be electronically pulled from a paragraph oftext. A recent upgrade of the Epic system allows for anew discrete field for rating patient progress towardmeeting the target outcome score. This new discretefield will allow for a more efficient method of access-ing data.


Resources for the Workshop

Resources selected were the NANDA-I classifica-tion book (NANDA-I, 2005) and a nursing diagnosishandbook (Ackley & Ladwig, 2006). One to two setsof resources were purchased for each of the teams:the nursing unit, the educational services, and the ITdepartment. The nursing diagnosis handbook was agood resource for searching for NANDA-I diagnosesappropriate for illnesses and diseases. However, thebook had some paraphrases and a limited index ofNOC indicators. The book also omitted some definingcharacteristics of the NANDA-I diagnoses. Theselimitations provided an obstacle to the abilities of theworkshop participants to create the new care plans.The participants used the four copies of NIC andNOC reference books during the workshop to com-plete the care plans created that day. AdditionalNIC and NOC references were purchased after theworkshop to use for later completion of the careplans.

Workshop

The Care Plan Task Force hosted a 1-day trainingworkshop to educate clinical SMEs on NANDA-I, NIC,and NOC. The workshop started in the morning with alecture on the nomenclature and its application todocumentation. Case studies were reviewed and staffbegan creating care plans in the afternoon. Nursesfamiliar with the nomenclature provided assistance tothe nurses creating the care plans.

Meeting with the Units

There was insufficient time during the workshop tocomplete all the necessary care plans. Therefore, thechair of the task force met with SMEs from each unitwith the exception of two, to create care plans thatwere not completed at the workshop. Four nursingunits had additional work sessions to finish the neces-sary development of care plans.

Review of Care Plans

The care plans which had been created and revisedwere sent to one of the consultants for review to ensureproper use of the nomenclature. The care plans werethen returned to the Care Plan Task force for finalapproval. This was to ensure that the care plans wouldappropriately reflect nursing practice at this facility.More than 140 care plans were either created or revisedby the task force and staff nurses.

The approved care plans were then submitted to theIT department to be built into Epic. Following the Epicbuild, the group again reviewed the care plans to checkfor content and spelling errors to ensure accuracywithin the project. Errors such as missing NOC indica-tors and typographic errors were found and correctedimmediately; however, not all errors were found.Additional errors were made during the move fromthe test environment to the production (live) environ-ment. There was no programmatic method to movecare plan templates from the test environment to theproduction environment. Therefore, the care plans hadto be rebuilt manually during the go-live by staff. Asecond review was required after the go-live to checkfor spelling and other errors and to ensure a profes-sional product. Errors were again found and correctedimmediately.

The Build

The new care plan format used the previously men-tioned description fields to display the label definitionfor the NANDA-I and the NOC. To use NOC as it wasdesigned, users needed to determine the proper indi-cators, assign an NOC rating at initiation and targetNOC rating. Drop-down lists were created to include aselection of the most commonly used indicators foreach NOC and the corresponding rating scales. Nursesselected the most appropriate indicators for the patient.If the indicators were not applicable, the nurse wouldadd additional indicators from the NOC referencebook. NIC interventions were assigned to each



outcome as appropriate. NIC definitions were notincluded on the intervention detail unless the author-ing SME decided further description was required.Refer to Figure 3 for the new care plan design. Figure 4represents the care plan design after the June 2007 Epicupgrade.

NANDA-I, NIC, and NOC did not completely meetthe hospitalized patient’s care plan needs. In addition,some diagnoses and outcomes that were appropriatefor the hospitalized patient needed revisions to reflectcurrent practice. New diagnoses and outcomes weredeveloped, and revisions were submitted to theNANDA-I Diagnosis and Development Committee(DDC) committee as appropriate. Diagnoses that werewritten and submitted include: Ineffective Tissue Perfu-sion: Cellular, Electrolyte Imbalance, Risk for Maternal–Fetal Distress, Hemorrhage, Increased GastrointestinalMotility, Dysfunctional Gastrointestinal Motility, andDecreased Gastrointestinal Motility. Risk for diagnoses

were also submitted for Electrolyte Imbalance, Hemor-rhage, Increased Gastrointestinal Motility, DysfunctionalGastrointestinal Motility, and Decreased GastrointestinalMotility. In addition to the diagnoses created, the Inef-fective Tissue Perfusion diagnoses were revised and sub-mitted. Nursing outcomes written and submittedinclude: Tissue Perfusion: Cellular, Safe Healthcare Envi-ronment, and Neurological Status: Peripheral.

Due to the naming convention used with the previ-ous care plan design, users had a difficult time identi-fying care plans that were appropriate for theirpatients. The new templates were named based onbody system, template name, or medical problem, aswell as other potential naming conventions. Forexample, the care plan “Appendectomy” had two syn-onyms: Gastrointestinal: Appendectomy, and Surgery:Appendectomy. This allowed users to intuitively findthe care plan templates they needed. The Spring 05Epic design does not allow for a synonym to be added

Figure 3. Care Plan Design December 2006. NOC, Nursing Outcomes Classification


to a care plan template so the build team simplycreated the care plans multiple times using differentnames but the exact same content.

Staff Education

Aspirus conducts a mandatory nursing in-servicethree times a year called the Triad. The task force heldhospital-wide educational sessions for nurses to prop-erly educate them on the use of the nomenclatures. Thesessions included NANDA-I, NOC, and NIC theory toassist nurses in understanding the language. The chairof the task force presented the systematic approach tocare plan organization in Epic with instructions forimplementation of a care plan using the new format.The concept of the rating scales and instructions for usewas explained. Interpretation of NOC indicators wasclarified and discussed using a case study approach

with participant involvement. The presentation was fol-lowed by a demonstration of the step-by-step processof using the care plan activity.

Feedback regarding the educational program wasmixed. While some nurses were excited about thechanges, others did not see the value in using careplans. Some negative quotes included: “This is notimportant to my job” and “This was a waste of time”.These comments reflect the challenges many hospitalsencounter regarding documentation and compliance.

The Go-live

Last minute changes were made to the displayformat of the outcome details. The indicators were relo-cated to above the NOC rating at initiation and targetNOC rating because this format is more intuitive. Thischange pushed back the go-live date by 1 month.

Figure 4. Care Plan Design June 2007. NOC, Nursing Outcomes Classification



Builders were required to change the format on everyoutcome already built and to continue building addi-tional care plans using the new format.

In addition to issues with the transfer of care plantemplates from the test to production environments,limited staff was available for assistance during thego-live. A total of seven people were available tosupport nurses in implementing the new care plansduring the go-live week. Volunteers from the task forceand Education Services rotated during the day andevening shifts to provide assistance. The decision wasmade not to provide support during the night shift dueto lack of resources. Some staff arrived at 6:00 a.m. toassist with last minute changes to care plans forpatients admitted during the night.

Monitoring Compliance

The task force created an audit tool to determinewhether the staff was using the care plans correctly.Much of the review focused on NOC as this is wherethe primary changes to the nursing workflowoccurred. Refer to Figure 5 for a view of the audit tool.

Initial monitoring showed that the staff did wellwith assigning the NOC rating at initiation and settingan individualized target NOC rating. However, thestaff struggled with documentation of the currentNOC rating each time they charted to the outcome.This was due to the new workflow and the lack of aspecific field for documenting the rating. The nursesneeded to remember to enter the NOC rating using acharting shortcut called a Smart phrase. A summary ofaudit reports can be viewed in Figure 6. An upgrade tothe Epic system in June 2007 improved compliance inthis area. A field was added to the care plan activitythat allowed the nurse to select the current rating froma drop down list.

Conclusions

Overall, the project was a success. Key factors inthe success of the project included: close collaboration

among staff nurses and IT staff (two of the IT staffinvolved in the project were nurse informaticists),ongoing support and encouragement from the VicePresident/Chief Nursing Officer, the ready availabil-ity of expert resources, and nursing ownership ofproject. Problems that occurred in the process werequickly identified and resolved because of the saidfactors.

Author contact: [email protected]

References

Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook:A guide to planning care (7th ed.). St. Louis, MO: Mosby.

Johnson, M., Bulechek, G. M., McCloskey Dochterman, J., Maas, M.,& Moorhead, S. (2001). Nursing diagnoses, outcomes, &interventions NANDA, NOC, and NIC linkages. St Louis, MO:Mosby.

McCloskey Dochterman, J., & Bulechek, G. M. (Eds.). (2004). Nursinginterventions classification (4th ed.). St. Louis, MO: Mosby.

Moorhead, S., Johnson, M., & Maas, M. (Eds.). (2004). Nursing out-comes classification (3rd ed.). St Louis, MO: Mosby.

NANDA-I. (2005). Nursing diagnoses: Definitions & classification 2005–2006. Philadelphia, PA: Author.

Appendix A

Reactions and Responses of the Laborand Delivery Unit Staff to the Introductionof Standardized Language and ElectronicCare Plans

In 2003 the hospital went live with electronic docu-mentation. All inpatient units including the labor anddelivery unit started electronic documentation ofassessments, medications and care plans. Care planswere moved from a paper care path to the computerbased “standardized language.” The unit staffexpressed frustration and anger about the mandatedchanges. The following examples illustrate the frustra-tions experienced and the subsequent discussions bythe professional nursing staff.


• The existing care path tool was paper based but hadstaff ownership and investment. The nursing staffexpressed frustration at the work wasted on con-struction and education of staff on this relativelynew care plan path.

• “Ours is a healthy population and the care pathswere marked by the predictable course of postpar-tum infant and mother.”

• The decision to move to care plan documentationwas not unit based. Some units were permitted touse care paths. Why not ours? I thought this was acollaborative process.”

• Concerns over original go-live include users notunderstanding nomenclature.

• Understanding the difference between progressnotes, documentation flow sheets, and care plans.

• Unit accustomed to documenting by exception.• “Documenting to” as opposed to just opening care

plan.

The resulting frustrations led to non-complianceand a determined collective response to chart thephrase, “progressing towards goals” on every careplan opened. This rendered the documentation

Figure 5. Care plan Auditing Tool. NOC, Nursing Outcomes Classification

Care Plan Monitoring Tool

We are monitoring compliance with care plan initiation,documentation, and updates. Please select a patient and completethe following form.

Unit____________ MR#____________ Date (month/year)________

Goal Statement Includes:

NOC Rating At Initiation Y N

NOC Target Rating Y N

Expected End Date Updated Y N N/A

NOC Indicators Addressed Y N

Care Plan Initiated By… Y N (.cpnew used when care plan opened)

NOC Rating With Documentation Y N

Documentation Within The First 8 Hours Y N

Documentation Every 24 Hours to each outcome Y N

Care Plan Reviewed Every 24 Hours (Review button checked) Y N

Interventions Changed / Updated As Appropriate Y N N/A

Variances Created With Change In Condition Or Goal Not Met On Discharge Y N N/A



meaningless. Nurses and physicians reported not evenreading care plans.

Recognizing not only this unit’s struggles but alsothe difficulties hospital wide, the Hospital Wide Prac-tice Council created a task force. The charge was to doresearch and improve the electronic care plans using theNANDA, NIC, and NOC standardized nomenclatures.Four members of the unit were involved in this taskforce. The nurses who were asked to volunteer rangedfrom young staff familiar with the language to seniorstaff with limited understanding of the concepts. Theleading change agent and force behind our representa-tion to this task force was our clinical nurse specialist.During the summer and fall of 2006, work groups meton the unit level to develop care plans and create tem-plates applicable to our practice. The work groups thentook our care plans to the task force for inclusion andcorrection before the upgrade. This upgrade was thefirst time staff was required to assign initiation andtarget ratings and to select indicators and interventions.

To forestall further resistance and to encourageownership in the product, our unit included educationabout new care plan structure in our fall skills day. Thefocus was dedicated to the technical aspect of using thecare plan product not to the language.

In December of 2006, the care plan upgrade wasimplemented. The unit moved and adapted moresmoothly but the care path mentality still prevailed.The new care plans were audited in February. Each unitwas expected to address their particular issues. Ourunit was identified as not opening care plans within anappropriate time frame and not documenting to eachcare plan opened every twenty-four hours. A mockdeposition with the hospital attorney was performedand videotaped at a unit meeting to bring home theimportance of complete documentation in obstetricaland neonatal nursing. In response, our unit based edu-cation chair developed a tool to walk people throughthe care plans and expectations. This tool was arequired education assignment and had a due date.The unit based practice council voted to require docu-mentation to the care plan at every shift.

Figure 6. Audit Results. CICU, cardiac intensivecare unit; CTU, cardiac telemetry unit;MAP, medical and pediatric unit; MSICU,medical surgical intensive care unit;NBBC, New Beginnings Birthing Center;NICU, neonatal intensive care unit; OCU,oncology care unit; ORN, orthopedicneurological unit; SCU, surgical care unit

NOC rating with Documentation

0%20%40%60%80%

100%120%

CICU

CTUIM

CM

AP

MSIC

U

NBBC/NIC

UO

CUO

RN

Rehab SCU

wHouse

wide

Week 1 Week 2 Week 3 Week 4

NOC Rating at Initiation

0%20%40%60%80%

100%120%

CICU

CTUIM

CM

AP

MSIC

U

NBBC/NIC

UO

CUO

RN

Rehab SCU

wHouse

wide


Target NOC Rating

0%20%40%60%80%

100%120%

CICU

CTUIM

CM

AP

MSIC

U

NBBC/NIC

UOCU

ORN

Rehab SCU

wHouse

wide



Where are we now:

• Confusion still exists in assigning targets to anessentially healthy population.

• Staff are encouraged to see patients as an at riskpopulation.

• Confusion remains about charting to outcomes andnot risk factors or indicators.

• Staff members are concerned and verbalize resis-tance to time spent away from bedside.

• Documentation during every shift is movingemphasis from care planning to progress notes. Thismandate was revisited at the practice council in June2007.

• Good representation on task forces; task membersmotivated.

• Creating care plans familiarized professional staffwith standardized nomenclature.

Challenges:

• Duplication of data (conceptual differences betweencare plans and document flow sheets).

• Use care plans during report.• Reducing time spent at computer

Appendix B

Evolution of the Neonatal ICU Care Plans

A new unit, the Neonatal Intensive Care Unit, wasopened in February 2006. The neonate requiring thislevel of care usually has multi-organ problems, espe-cially if born prematurely. Most other nursing diag-noses at Aspirus would be classified by bodysystems, but the need for something more multifac-eted for these very small, but very complex patientswas evident. To develop into a healthy, normalperson, these infants now must survive in the worldoutside of his or her mother with the care of theinterdisciplinary team of the NICU. Issues like ther-

moregulation, gas exchange, infection severity, nutri-tional status, neurological status, infant behavior, andpotential impairment of parental attachment are pos-sible complications of extrauterine transition for aneonate.

The interdisciplinary team consists of neonatology,nursing, respiratory, physical, occupational, andspeech therapy, as well as clinical nutrition and socialservices. All these disciplines needed a method ofdocumentation to communicate with each other to suc-cessfully care for the high-risk babies. To do this, theClinical Nurse Specialist for the Birthing Center led theinitiative to bring NANDA, NIC, and NOC to theNICU as well as to the Birthing Center.

In August 2006, the NICU interdisciplinary careplans needed clarification of the requirements regard-ing other interdisciplinary team members. Educationwas necessary in developing these care plans correctly.Aspirus’ documentation specialist was consulted toensure proper building and implementation of inter-disciplinary services’ documentation specific to neona-tal needs. Special arrangements of care plans wereconsidered for reimbursement of such therapies.

The chairperson of the Aspirus task force, and thedocumentation specialist met with interdisciplinarytherapies to develop care plans. A care plan titled “Dis-organized Infant Behavior” was created for nursing,occupational therapy, and physical therapy to utilize. Itwas agreed to have nursing and therapies share anursing diagnosis, with the therapies having their ownoutcome to document on and interventions specific toeach therapy or to nursing. In addition, a care plan wascreated to encompass all patients of every age for occu-pational therapy and physical therapy.

A care plan titled “Ineffective Feeding Pattern” spe-cific to the NICU was also developed to collaboratenursing, clinical nutrition, and speech therapy. Socialservices had a care plan titled “Risk for ImpairedParent-Infant Attachment,” which addressed the adap-tation and attachment of the parent to the infantneeding long-term hospitalization.



implementation of standardized nomenclature in the electronic medical record

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