Transforming Nursing Documentation

Graduate nursing education is positioned to transform nursing documentation so that it more fully describes nursing assessments, diagnoses, interventions, and outcomes to measure improvements in care. Learning to document with structured nursing terminology is an integral part of "Information Technology for Evidence-Based Practice", a required online course taken by all students in the Rutgers Doctor of Nursing Practice program. Beginning with SOAP and terminology required for billing, students create a clinical note adding elements of the Nursing Minimum Data Set, using Clinical Care Classification terms. Next, students are asked to select a nursing-related clinical practice guideline, electronic clinical quality improvement measure, and a screening tool that applies to their encounter note. Then, they identify Patient Reported Outcome Measures as well as improvement activities in the CMS Quality Payment Program. The course is well-received; many graduate students now face changes in documentation and electronic tools and can predict future evolution.