Creating a system of Documentation

1
Creating a system of Documentation

• Objectives
• To understand and overcome the barriers that
  hinder compliance with implementation of a stoke
  protocol set
• Obtaining and maintaining staff competency for
  stroke protocol at a rural/critical access
  hospital

2
Goals of a Good Documentation System

• Improved treatment and care of the stroke patient
• Improved and interactive communication between
  physician, staff, and patients and their families
• Assists with any quality improvement process
  related to stroke care

3
Documentation should include..

• Use of Stroke order/protocol sets that include
• Orders
• Protocols for stroke patients
• Patient and family education information
• Physician checklist
• Patient discharge instruction forms or
• Transfer form

4
Barriers

• Physician or staff unwilling to use/follow
  protocols
• Poor communication or interaction with a tertiary
  stroke hospital
• Nursing staff unwilling to use/follow protocols
• Poor documentation

5
How do we overcome documentation deficiencies?

• Physician champion
• Nursing champion
• Ease of use and clarity of protocols or forms
• Good communications with tertiary hospital stroke
  center
• Staff education (and ongoing re-education)
• Willingness to revise protocols and forms to meet
  best practice and assist with documentation.
• Front-line staff involvement in the process
  (from protocols to revisions and process changes
  to enhance care)
• Work with tertiary stroke hospital to best meet
  the patients needs and documentation
  requirements

6
Contact with a tertiary stroke hospital

• ED Medical Director establish a relationship with
  neurosurgeon at tertiary stroke hospital
• Obtain their protocol and documentation forms
• Mirror your protocols and forms to reflect
  similar protocols and documentation forms

7
GWTG benefits

• Graphical illustrations for immediate feedback
  and to share with physicians, committees and
  nursing
• Use collected data information for other quality
  processes
• Educational material for print out
• Physician and patient letter printout capability
• All of the above assist with improved processes
  and benchmarking

8
References

• Please refer to
• AM, HF PN protocols implemented by Dunn
  Memorial Hospital
• Discharge Instruction Form
• Physician checklist

9
Thank You

• Donna Sexton RN
• Performance Improvement Manager
• Dunn Memorial Hospital
• Bedford, Indiana