Implementation of a computerized resident care system for enhancement of patient care and dietary services in a long-term care facility

Abstract

Nursing Homes have felt the impact of increased medical record documentation and demands for overall higher quality patient care with the outcome focus of the Omnibus Reconciliation Act of 1987 (OBRA 87). To meet regulatory requirements, save documentation time, promote team work, and deliver higher quality care, Sandalwood Convalescent Home implemented a computerized resident care system (RCS). The system maintains information in four major areas of resident care: resident and weight information, assessments, care plans, and physician's orders. Data is collected from professional staff including physicians, nurses, dietitians, social workers, activity directors, and rehabilitation professionals. Specifically, dietitians are responsible for completing the dietary portion of the data collection tool. This tool then generates the nutritional assessment and patient tray card. The dietary data also triggers Minimum Data Set (MDS) automatic and potential nutrition related triggers on the patient care plan and Resident Assessment Protocols (RAPs). All disciplines complete their data collection tool in a similar manner as dietary. All data is input into the computer; then, a true comprehensive assessment and comprehensive care plan is generated for the resident as well as a MDS and RAP. The RCS is updated on a continual basis so additional valuable reports can be generated such as weight variance trends, albumin levels, food preferences, and dietary cardexes. Implementation of RCS requires facility readiness, orientation and training workshops and team support. The system has saved the dietary department alone a minimum a four hours/week by speeding up dietitian documentation and decreasing tray card sorting time; this does not account for the increased accuracy of tray cards and time saved in changing tray cards. With time saved and accuracy improved in all departments, RCS encourages team work within the facility and assists the health care team in providing quality patient care.