Embedding clinical indicators into nursing documentation

The Methodist Healthcare System of San Antonio audits completeness and accuracy of nursing assessments. Between 1996 and 2001, regardless of software enhancements and education, completeness of risk assessments hovered at 80% or less. Accuracy of risk scores were in question due to paste functionality. In review, it became apparent that many risk assessment indicators were already an intrinsic part of nursing systems assessment. This project embedded weighted indicators invisibly within systems assessment. Risk scores then automatically calculate and display. This approach decreased documentation queries and increased accuracy of risk assessments. Results were validated using concurrent manual review. Skin assessment demonstrated a 96% accuracy rate with 100% completeness of documentation. Fall assessment resulted in a 2.5% miss rate and 100% completeness of record. 100% of high risk patients identified had appropriate care plan problems. Recommendations are to further explore embedded indicators in software design. The study demonstrated a) decrease in nursing documentation queries b) increase in completeness of record c) increase in accuracy of record and d) increase in accuracy of care plan.