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08/16/11
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Nursing Practice Councils
Ancillary departments
February 16, 2012
Clinical Practice Guidelines/ Knowledge Based Charting
Overview and Demo
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Purpose of Meeting
Introduce the QUEST Phase 4 Clinical Documentation project Solicit interested nursing and ancillary dept staff to participate in design sessions Determine acceptance for the use of Clinical Practice Guidelines (CPGs) using Knowledge Based Charting (KBC)
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Agenda
Introduction by Karen Grimley, CNO
Overview/Timeline of Phase 4
Request for design advisors
Project guiding principles and assumptions
KBC/CPG definitions and overview
Demo
Discussion
Vote
Next Steps
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Phase 4
Clinical Documentation
Device Integration
Bar-Code Medication Administration (KBMA)
Patient Classification System (Acuity)
Supporting Strategies: Point of Care (Bedside) Devices, Voice Recognition, TDS Retirement
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Design Advisors Wanted
Represent your council, unit/division/department
Be a permanent member of the Design Team
Attend weekly meetings ( Tuesday mornings, 4 hours) through the end of the year
Solicit input and communicate back to staff
Participate in testing
Participate in training
Serve as Super Users/Red Coats at implementation
Interested? Email meobrien by Feb. 24
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Project Guiding Principles
UC Irvine Medical Center’s clinical systems development shall support our mission to provide quality care and the objectives of the School of Medicine.
We shall incorporate best practices and evidence based clinical content into a standardized configuration for use throughout the Medical Center.
Decision making and design shall be the result of direct participation by frontline care delivery providers whose work is supported by automation.
Our decisions shall be based on doing what is best for the Medical Center as a whole -not a single individual area.
Our care delivery shall be relationship based, collaborative, interdisciplinary, and rooted in clear scopes of professional
practice.
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Project Assumptions
System supplied content will meet 80% of our build need
Voice Recognition may or may not be available by go-live
Selected documents will not be included in initial implementations:
- Intra-procedure/sedation records
- Code Blue documents
- Consents
- Patient questionnaires
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Why we are here
Determine acceptance for the use of Clinical Practice Guidelines (CPGs) using Knowledge Based Charting (KBC)
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Clinical Practice Guidelines
Developed by the Clinical Practice Model Resource Center since 1983 (now part of Elsevier)
Evidence based including Consortium member validation
Over 200 medical, surgical, maternal-child and human response diagnoses
Gives clinicians practical direction regarding assessments, diagnosis and treatment across nursing and allied health disciplines in acute care settings.
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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CPG PDF Format (with Grading of Interventions)
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NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Clinical Practice Guidelines: CPG’s
•Guidelines are not prescriptive and do not provide a rigid pathway for diagnosis and treatment.
•They represent an aggregation of the best information on the specific topic, including signs/symptoms, complications, interventions, goals and outcomes.
•The Elsevier CPM approach provides the caregiver with the flexibility to make informed, independent decisions based on the best available information.
•Specific treatment plan remains the purview of the provider.
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NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Problem Identification
Establish Goals/Outcomes
and Provide Education
Assess and Evaluation
Interventions/ Treatment
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Dietitian
Nursing
Respiratory
Care
Reflect Professional
Scope of Practice
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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CPG Benefits
Safe, consistent and streamlined care based on the latest evidence
Individualized, patient-centered care at the point of care
Standardization of clinical documentation
Streamlined regulatory compliance
Fosters interdisciplinary collaboration
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Knowledge Based Charting (KBC) is the Allscripts expression of the CPG content into Sunrise and incorporating Sunrise functionality
Additional Content released by Allscripts
Knowledge Based Charting
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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KBC Delivery: Layout
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Patient Populations
Adult
OB
Pediatrics
Newborn
NICU
Main Flowsheets
Plan of Care (POC)
Assessment/Intervention
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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CPG and KBC
A CPG is composed of •Goals/Outcomes •Assessments •Interventions •Education
When a CPG is added to a patient, observations become active across the flowsheets The flowsheet is the patient centered interdisciplinary documentation record
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NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Plan of Care/CPG Integration in Documentation
Guideline
Assessment
Assessment
Intervention
Flow sheet
Education/Outcome
Record
Plan of Care
CPGs
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Documentation Framework
Planning Care
Patient
Education
Evaluation
Toward Goals
Evidence
Based
Content
Learning the
Patient’s Story
Providing Care
Report: Exchange between Professionals
NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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Demo
•What the Flowsheet looks like
•How CPG content fills the flowsheet
•How the content informs nurses and ancillary providers on the best care to provide
•How to document on the flowsheet
•How to view what was documented
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NK9g, Clinical Practice Guidelines KBC Overview and Demo to Nursing.pdf
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