Abstract TP43: Optimizing System-Wide Nursing Assessment Documentation in the Stroke Population

Abstract

Background: Stroke centers following AHA guidelines for the treatment of acute ischemic stroke, are challenged by compliance with documentation of vital sign, neuro and neurovascular assessments post thrombolysis interventions. Standardizing documentation in the electronic health record (EHR) increases compliance and reduces patient harm. In a large healthcare system, multiple sites received corrective action findings from regulatory agencies for missed nursing assessments. The centers did not have a documentation workflow aligned with the EHR to capture assessments in the stroke population. Purpose: To create a system-wide documentation workflow that captures nursing assessments in the EHR. Methods: In 2019 a task force of stroke coordinators and clinical informaticists convened to define evidence-based nursing assessments in stroke patients post intervention, define within normal limits for each component, and identify barriers to documentation in the EHR. The EHR was evaluated for component location and other areas in need of optimization. Components were scattered across different EHR locations, leading to missing documentation and assessments were difficult to trend. The task force led the development and implementation of a single EHR location to document nursing assessments. The EHR revisions were implemented in July 2022 after being vetted by system EHR governance, nurse practice council, and stroke coordinator collaborative. Results: A single grouping was developed in the EHR including vitals, focused neurological and neurovascular assessments. This grouping was strategically placed within nursing’s existing workflow. Reference text addressing each element of the grouping and its “within defined limits’ definition were added to align with the organization's documentation standards. To increase visibility of documentation, trending, and the auditing process, a single results view was developed which included all documented assessment components. Conclusion: A system-wide documentation workflow aligned with the EHR optimized documentation workflow, improved visibility of assessments, reduced audit time and regulatory findings. Stroke centers should carefully consider the layout of nursing documentation in the EHR.