Nursing Record Innovations Aimed at Harmonizing Structured Clinical Knowledge Among Doctors and Nurses

Area of Science:

• Healthcare Management
• Clinical Informatics
• Nursing Informatics

Background:

• Hospitalization expenses constitute a significant portion of Japan's national medical expenditure, reaching 36.8% in 2015.
• Nurse labor costs represent approximately one-fifth of general hospital expenditures, highlighting their substantial impact on hospital management.
• Current nurse record-keeping is time-consuming and of poor quality, necessitating improvements in accessibility and efficiency.

Purpose of the Study:

• To enhance nurse record-keeping processes for improved accessibility and reduced time spent on documentation.
• To harmonize structured clinical knowledge between physicians and nurses.
• To streamline the creation of foundational nursing plans through interdisciplinary collaboration.

Main Methods:

• Development of 778 Patient Condition Adaptive Path System (PCAPS) items across all clinical departments.
• Integration of PCAPS content with the "Team Compass" application for standardized sharing among hospitals.
• Linking electronic medical records with Team Compass to summarize clinical progress sheets and clinical orders.

Main Results:

• Successful summarization of clinical progress sheet information by linking electronic medical records and Team Compass.
• Facilitation of collaborative foundational nursing plan creation by enabling smooth information sharing between nurses and doctors.
• Implementation of Team Compass in May 2019, with PCAPS-based care pathways used for 580 inpatients on the first day.

Conclusions:

• The Team Compass system, utilizing PCAPS, effectively improved nurse record-keeping processes and interdisciplinary collaboration.
• The system demonstrated successful integration and adoption, treating approximately 4,000 patients between May and August 2019 without major issues.
• This approach offers a viable solution for reducing hospitalization expenses by optimizing nursing workflows and enhancing clinical knowledge harmonization.