22. Care Coordination Care Delivery Clinical Coding Provider Assessments (InterRAI / Target) Care Planning(OMAHA System) Assessments & Allocations(InterRAI) SNOMED-CT Terminology(OMAHA System)
23. Four Stage Project Document Terms and Definitions and develop a community clinical data set referencing: OMAHA system InterRAI SNOMED-CT Community nursing & Allied Health documentation Develop clinical record Produce software specifications / requirements, develop and test the electronic prototype Implementation / Roll out. Staff will be trained in the use of the mobile technology and the clinical record
24.
25. The Documentation Database Over 800 individual data elements across 42 forms Some data elements collected several times on one form Some data elements collected numerous times across the organisation (up to 46 times) Thousands of separate pieces of information recorded on the forms
26. Documentation Database Cont. 18% of the data was demographic Up to 30% of other data was duplicated Limited standardised information about treatment & procedures No space or place to record case management, teaching, guidance & counselling
We’re facing a new and largely unknown world in healthcare and we need transformers to deliver care in the new landscape.
In 2009 Nurse Maude commenced a project with the end goal to improve clinical practice through the use of a clinical information system. The clinical system was also viewed as an opportunity to improve data capture and outcome reporting on the care delivered. Informatics Nurse Brent McGrath presented last year at HINZ on the development of this project and his sudden death this January has been a huge blow in losing such an intelligent and talented nurse. I would especially like to acknowledge his work which has shaped the project and led us on the pathway we are continuing on. I also would like to acknowledge my colleagues Shona Wilson, Kay Poulsen and US colleague Karen Monsen for their insights. The project set out to Improve clinical care through developing standardised and systematically designed documentation using recognised systemsetc
We have completed the first stage of the project and recently commenced stage two. The first stage of the project included:Aligning the terms of the Omaha System, with the terms of the Nurse Maude clinical guidelines and SNOMED-CT as they relate to concepts and definitions.Aligning the Client Assessment Protocol Summary (CAP) triggers from InterRAI tools (Minimum Data Set – Homecare (e.g. MDS-HC), with the problem classification scheme of the Omaha System, Nursing Outcomes Classification Scheme (NOC) and SNOMED-CT concepts toward common terms.Undertaking a workshop with expert community care clinicians to establish congruency between the terms and the colloquialisms of current practice to develop the terms and descriptions of the dataset.Development of the CADI data set