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Knowledge enabled plan of care and documentation prototype
Rebecca DaDamio1, Brian Gugerty, Rosemary Kennedy
1Siemens Medical Solutions-Health Services Corp., Malvern, Pennsylvania, USA.
Studies in Health Technology and Informatics
|November 15, 2006
Summary
Integrating a plan of care into clinical documentation is challenging. This study demonstrates a knowledge-driven computerized solution that fully integrates the plan of care into nursing documentation, improving goal-directed care.
Area of Science:
- Clinical Informatics
- Nursing Informatics
- Health Information Systems
Background:
- Integrating patient plans of care into electronic health records and workflows presents significant challenges.
- Current plans of care are often static, meeting regulatory needs but not actively supporting goal-directed care delivery.
- This limits their utility in real-time clinical decision-making and process improvement.
Purpose of the Study:
- To demonstrate a knowledge-driven computerized solution for fully integrating the plan of care into clinical documentation.
- To highlight the application of this solution within nursing processes.
- To showcase its potential for improving goal-directed care delivery and quality improvement.
Main Methods:
- Development of a prototype knowledge-driven computerized solution.
- Integration of a comprehensive knowledge infrastructure, including controlled terminology and structured clinical expressions.
- Demonstration using nursing processes to illustrate the system's functionality.
Main Results:
- The solution effectively integrates the plan of care within documentation systems.
- It supports managing patient problems, orders/interventions, and progress toward outcomes.
- The system reflects evidence-based practice and meets regulatory standards.
Conclusions:
- A knowledge-driven approach can successfully integrate the plan of care into clinical documentation.
- This integration enhances goal-directed care, quality improvement, and regulatory compliance.
- The solution offers a valuable tool for nursing and potentially other clinical disciplines.
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