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At Long Beach (NY) Medical Center, separate physician order and nurse’s documentation (medication administration and lab studies) forms have been combined, providing several significant benefits for both staff and patients.
The new paperwork regimen has been instituted for patients in selected circumstances — thrombolytics administration for cerebrovascular accident (CVA) or myocardial infarction (MI) and for emergency room (ER) patients with unstable angina, MI, or rule out (r/o) MI, according to Cheryl Caparros, RN, MBA.
The reasons behind the new paperwork format used for ER patients with unstable angina reflect those for all the new forms, she says. "When treating this type of patient, the physicians typically have a treatment protocol, which they often keep inside their heads," she explains. And under the old way of doing things, "The physicians would have to either write out their specific orders or give verbal orders for the nurses to put on the patient’s chart." In the latter, nurses would have to transcribe physician orders into the medication administration record, says Caparros, "or try to squeeze them into a little corner of the chart somewhere, which was difficult, because our chart really didn’t have a large section for physician orders."
This inefficient system of communication/ record keeping led to problems, according to Caparros. Because of the errors in translating physician handwriting and/or problems in transcribing written physician instructions, maintaining accurate medical administration records was difficult. "Sometimes transcription worked; sometimes it didn’t. But it never worked as well as we would have liked it to."
At the same time it was beginning to tackle these communications problems, Long Beach Medical Center was participating in a Cooperative Cardiovascular Project sponsored by IPRO (Island Peer Review Organization), a Long Island-based, nonprofit health care quality improvement organization. The project’s objective was to improve the identification, treatment, and care of patients with acute MI in New York hospitals, according to optimal patterns of care as identified by the medical literature and practice guidelines. "[IPRO] wanted to standardize protocols/interventions among participating hospitals," says Caparros. "And we thought that if we could combine the physician’s order form with the nurse’s documentation record, we would kind of be killing two birds with one stone," she says, alleviating the internal paperwork problem while achieving new performance goals.
The new forms for thrombolytics administration for CVA or MI, and for ER patients with unstable angina, MI, or r/o MI now have recommended orders, according to accepted protocols, that are pre-printed in a table format. The physician can opt to implement the recommended order set by signing, timing, and dating the top of the form, or can indicate specific orders and associated times by signing/timing in columns next to each order. The nurse then documents the medicine administration and/or the initiation of lab studies and other actions by signing and timing the next column.
"Combining physician order sheets with nurses’ documentation eliminated the need to transcribe orders to another form, eliminated the possibility of transcription error, and saved time," says Caparros. And more importantly, the new forms help standardize the steps taken to care for patients, she notes.
Implementation of the new form "has gotten off to kind of a slow start," says Caparros. Old habits can be hard to break without constant reminders. "Even though we had gotten the emergency department physicians involved very early on in the development of the form," she says, "they still sometimes forget to initiate it." As a result, "We’ve often had to go back and remind them that one of the reasons we have this new form is to make things easier for them."
[For more information, contact Cheryl Caparros at Long Beach Medical Center, 455 East Bay Drive, Long Beach, NY 11561. Telephone: (516) 897-1316. E-mail: firstname.lastname@example.org.
To get more information about this and other innovations in health care, go to www.best4health.org, the site of The Best Practice Network, an organization devoted to promoting information sharing and experience exchange among nurses, physicians, and other health care professionals. For more information on The Best Practice Network, e-mail email@example.com, or call (800) 899-2226.]