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Care planning with the electronic patient record

VOL: 101, ISSUE: 37, PAGE NO: 26

Carolyn Mills, MSc, PGCEA, BSc, RN, is director of nursing at North Devon Healthcare NHS Trust

Maria Rajwer, BSc, RN, is electronic patient record process review analyst at University College London Hospitals NHS Foundation Trust;Anthony Pritchard, MA, BSc, RN, is an independent consultant nurse

Obtaining reliable health information of various types from differing sources at the right time, for the right person, is important to the provision of planning safe and effective patient care. Electronic patient care plans enable health care professionals to access information and knowledge during the assessment, planning, delivery and evaluation of patient care. Technology provides a direct link with evidence-based information and knowledge.

Obtaining reliable health information of various types from differing sources at the right time, for the right person, is important to the provision of planning safe and effective patient care. Electronic patient care plans enable health care professionals to access information and knowledge during the assessment, planning, delivery and evaluation of patient care. Technology provides a direct link with evidence-based information and knowledge.

National context
Lifelong electronic health records for everyone are a key component of future national health strategy (DoH, 1998). The development of a single electronic record is critical to the delivery of The NHS Plan, and future information technology needs to be designed around the requirements of patients and service users (DoH, 2001).

This requires a nationally integrated programme for the future development of health information technology (Wanless, 2002). A strategy for health information technology was developed in 2002 (DoH, 2002a) initiating a National Programme for Information Technology, now NHS Connecting for Health. The core aims of this are to develop a national strategy for the introduction of an NHS care record for each patient (DoH, 2002b).

Electronic patient records
The move of many services to a new building at University College London Hospitals provided an opportunity to standardise practices. This, with the national IT agenda, provided the trigger for the local review and development of the electronic patient record (EPR) system. Nursing documentation was developed in the second phase of the project.

The core objective was to develop an integrated trust-wide approach to nursing documentation in the context of future multiprofessional patient care planning. It was important to dovetail these trust developments to the wider national IT programme, while using local experience to inform the wider national development of care records.

The project offered an opportunity to develop a system that maintained the patient as the focus, while reflecting current and future ways of working for staff. Active engagement of staff and liaison with user representatives were key priorities.

Effective and collaborative working between the key stakeholders - the system providers, the trust EPR project team and nursing representatives - was required. Electronic patient plans were considered in the context of an interrelationship between the patient, the organisation and technology/EPR.

The aim for patients was:

- To provide patient-centred care;

- To support appropriate individualised care;

- To support collaborative working between the patient, their 'family' and health professionals;

- To support a consistent, evidence-based approach to care planning.

For the organisation it was:

- To increase organisational communication throughout the patient journey;

- To provide a mechanism for audit;

- To facilitate safety and risk management;

- To facilitate developing knowledge and skills;

- To ensure ownership and participation in developing electronic patient care planning;

- To support future developmental strategy.

The aim for technology was:

- To be user-friendly, understandable and intuitive;

- To increase accuracy and speed in documenting patient care;

- To improve access to evidence-based information/national guidelines;

- To facilitate improved communication;

- To provide operational and performance tools;

- To provide an audit function for daily hospital processes and future projects;

- To replace the existing, outdated system with fit-for-purpose EPR;

- To support the new hospital, which is designed to be 'paper-light', with technological developments supporting EPR.

Care planning
The initial objective was to assess the care planning function of the provided software, while identifying organisational needs. The system initially presented patient care needs as a task list. A key requirement was for these to be presented in a hierarchical structure, identifying a patient problem, the related goals and a range of potential interventions within each goal. This would reflect the process that underpins nursing (Fig 1) (Pearson et al, 1996) as opposed to a task-orientated approach.

An early need was to identify a framework for the assessment and planning of care. The care plan is created through a patient assessment. It was important to consider the future approach to multiprofessional documentation. A mapping exercise compared traditional nursing frameworks, a medical or 'systems' model, international SNOMED (Systemised Nomenclature of Medicine) terminology classification (CAP, 2005) and a framework of functional health patterns (Gordon, 1982).

Functional health patterns emerged as the most comprehensive framework for considering the various aspects of an individual. Applicable to a variety of differing professional perspectives, it was selected as a basis for developing patient assessment and planning information. The content of an initial adult and paediatric assessment tool was developed.

Nursing diagnosis (Gordon, 2002) was considered as a potential approach to developing patient care plans. Although this provided the opportunity to standardise terminology, it was considered that it might limit reflection of individual care needs and might not reflect the language of the patient. It was decided to develop patient care plans through identifying patient problems, with related goals and interventions forming patient plan templates.

Generic patient problems (requiring a similar plan of care regardless of location or specialty) and distinguished problems (unique to a distinct specialty) were identified, and potential goals and interventions developed. The completed plans were then peer-reviewed prior to data entry. A database was developed to help coordinate data collection and transfer of information to the software providers.

Electronic patient care plans provide the opportunity to link patient problems, goals and interventions to related policies, procedures and guidelines. This supports evidence-based care and treatment while providing an educational function for staff. A further benefit is the linkage to relevant health information that can be accessed by the patient.

The process of documenting the evaluation of care and treatment was considered. The trust's previous system provided evaluation only against goals within a patient plan, with no facility to view planned interventions to meet this goal. Representatives agreed that evaluation in the revised system should be against the planned individual interventions within a patient plan. This was important in ensuring an accurate record of care and treatment.

A trust-wide documentation policy that reflects professional and legal requirements was developed, as well as a mechanism for making changes to the content of the system to enable ongoing evolution of patient plans. This ensured a formalised approach to future content changes.

Implementing a pilot involved reviewing and editing the information within hundreds of patient care plans. The paper documentation reflected the content of the new electronic patient care plan and the purpose of the pilot was to test the data while allowing clinical staff across the trust to familiarise themselves with the new approach.

Outcomes
This project has standardised a range of differing approaches to nursing documentation, and developed a common approach to assessment, planning and evaluation of care through an electronic patient record. It has allowed consideration of the ways IT can support professional staff in providing evidence-based, patient-centred care and treatment.

The work involved a reciprocal process of learning between the worlds of technology and clinical practice. The challenge was for clinical staff to articulate their day-to-day practice and for this to be interpreted from the perspective of technology. We further learnt that any nursing information system can only provide a structure for individualised patient care. The true potential of any system is only achieved through the nurse applying skilled knowledge and decision-making to the care planning process.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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