From Old School to New: Leveraging functionality of clinical documentation software to transform a classic Nursing tool

Purpose:
One of the largest dissatisfiers with charting software has been the ability to quickly see a comprehensive electronic snapshot of pertinent patient information. The goal was to leverage the software's capabilities using a model designed by clinical staff to create an electronic Kardex or eKardex.

Significance:
Improvements in patient safety afforded by an eKardex during transitions of care are paramount. Second, clinical staff satisfaction is greatly improved through participation in the design and implementation of the clinical documentation system.

Strategy and Implementation:
At UNC Health Care, the development of our electronic clinical documentation system (eChart) has been guided by the Clinical Design and Implementation Committee (CDIC). The CDIC is comprised of Nursing representatives from every service line, Nursing administration, Pharmacy, Respiratory Therapy, OT, PT, SLP, Food and Nutrition Services, Performance Improvement, Compliance, Legal, and IT. For the past 5 years, the committee has continuously reviewed and revamped clinical documentation and documentation processes. CDIC helped develop functionality in eChart that mimics that of a traditional paper kardex. The snapshot of patient information contained within this new eKardex is a by-product of ongoing clinical documentation and is updated automatically as new data is entered. The eKardex allows for logical groupings of information that may have been charted across various assessments throughout the entire patient's stay.

Evaluation:
Implementation of the eKardex has been a huge satisfier for clinical staff. This success is a testament to: 1)the value of clinicians designing documentation tools for their fellow clinicians and 2)the reuse of classic Nursing tools in the brave new world of electronic clinical documentation.

Implications for Practice:
The value of the eKardex is most evident when used as a communication tool during patient hand-off, shift report, and other transitions of care.