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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
PubMed
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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.

Related Experiment Videos

  • 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.