"ROCK" with ClinDoc (Research, Outcomes, Case Review, Knowledge)

Purpose:
We implemented ClinDoc, an electronic nursing documentation system, to streamline and improve timeliness and accuracy of documentation. We intended to maximize accessibility of the database by all types of caregivers, specifically to nurses involved in quality and process improvement.

Significance:
Improving patient information accuracy contributes to effective resolution of nursing diagnoses. Communication among nursing team members and interdisciplinary colleagues is maximized. Data are readily accessible to demonstrate need for process improvements and effectiveness of such improvements.

Strategy and Implementation:
ClinDoc implementation planning began five years ago with the initiation of eMAR, our electronic medication record. Nursing staff have been integral in the planning process along with interdisciplinary colleagues. Extensive nursing staff training for over 2000 employees was completed, with documentation experts designated in each nursing unit. Implementation occurred in "Big Bang" fashion, with all nursing units going live at the same time. Implementation was extremely smooth, with very few challenges, all of which are resolved. Nursing Quality Improvement Council representatives, Nurse Managers, members of our Unit-Based Councils, and members of our Pain Resource Team all access the database to assess effectiveness of processes, and conduct case reviews for patients with less-than-optimal outcomes. Information is shared with all nursing colleagues and integrated into practice change.

Evaluation:
Nursing staff are very positive about the operation of ClinDoc and the ease of data retrieval. They are becoming more familiar with using data for process improvement through individual practice and review in shared governance structures.

Implications for Practice:
Documentation processes have changed radically, with a significant increase in documenting at bedside. Data are available in real time, so many individuals can view the same patient's information simultaneously for remote discussions. Process improvement plans are all data-driven.