February 26, 2013
Here at Epic, we’re not shy when it comes to bragging about our outstanding team of nurses and therapists. They not only provide outstanding care to our clients, but also are at the forefront of improving the home care industry.
One outstanding nurse is Dr. Jill Peacock, regional clinical director for our Northeast offices.
In January, Dr. Peacock’s research article – titled “Translating Best Care Practices to Improve Nursing Documentation” – was published in Home Healthcare Nurse. Dr. Peacock collected the data from a company not affiliated with Epic.
“I focused my research on nursing documentation because it is so important to what we do and the quality of care we provide our clients,” said Dr. Peacock. “What I discovered was that the documentation did not always capture the complexity of care needed by medically fragile children requiring tracheostomies or mechanical ventilation.”
The six-week implementation phase began with a thorough review of a preexisting flow sheet and guidelines. The audit revealed that the flow sheet was not capturing essential clinical data.
The nurses enrolled in the study were then instructed on how to use a new standardized flow sheet that provided cues on the type of clinical data that needed to be recorded.
“When you are delivering skilled nursing care for clients with complex medical conditions, the documentation must be standardized in order for the care to be adequately and accurately assessed,” said Dr. Peacock. “In many cases, the documentation is used to determine compliance with a physician’s orders.”
After the new flow sheet was fully implemented, Dr. Peacock found that the quality of documentation significantly improved. She also noticed a high percentage of compliance with the new tool and guidelines.
“While the research was never designed to measure quality of care, I have heard from nurses who have used the tool and applied it in a way that had a positive outcome in the care they provided,” noted Dr. Peacock.
Standardizing the documentation tool also accomplished the following:
1.) Ensured critical or essential clinical data would be captured and standardized so that all nurses in the home were assessing and recording the same data
2.) Ensured that those who were auditing the flow sheets were looking at and evaluating the same data elements
At Epic, we use standardized flow sheets to document care and capture critical elements. Our clinical supervisors educate nurses on use of the nursing care flow sheet and review the documentation to ensure compliance as well as quality of care.
Congrats, Dr. Peacock, on your recent publication. We look forward to hearing more about your future research!