DATE: June 17, 2009
FROM: CV Service Line Education Team
* 2009 Care Transformation Process Improvement E*ducation *& E*valuation
S: (Situation) – The Cardiac Treatment Center at BGSMC has identified an opportunity to improve the process of documentation through care transformation for patients undergoing the following procedures:
a patient from the cardiac catheterization lab that will be discharged the same day;
a patient from the cardiac catheterization lab with or without intervention that will be admitted;
an Electrophysiology patient;
and a chest pain observation.
Additional Info
Patient Education
Discharge and/or Transfer Form
Admission Health Profile
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R: (Recommendation) - Design and implement a patient population driven charting process to include a set of electronic forms to be completed. The expectation is that all nurses will electronically document in the same manner for the specific population they are caring for regardless of skill level. The exception would be for an ICU level nurse that is caring for an ICU patient to chart on the appropriate ICU forms.
GOAL: Improve the quality and efficiency of patient care through standardization of charting. This updated process will be effective . It will be required for all RN’s to follow the standardization process.
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An educational record will be maintained
Provide and recruit bedside nurse champions as a resource.
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Conduct random chart audits to identify compliance with new charting process.
Reevaluate new process with staff in 3 months from start date.