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Focus shifts from filling in forms to patient care

Photo left to right: Michelle Richardson, Sue Hayward and Melody Mitchell with the assessment flipchart.
Photo left to right: Michelle Richardson, Sue Hayward and Melody Mitchell with the assessment flip chart.

Nursing Documentation Project – it sounds as dry as a bone, but in fact this four-year improvement project ticks all the positive boxes. It has dramatically reduced the number of forms nurses use for assessing patients, and instead refocuses them on patient care and what really matters to each patient.

That’s why the project has received high levels of engagement and support from nurses across Waikato District Health Board including its rural hospitals and community-based nurses.

And that, in turn, means its implementation starting in mid-May is likely to be welcomed and succeed.

The journey has been painstaking but for good reason. Nurse educator Michele Richardson and nurse manager Melody Mitchell, with sponsorship from chief nursing and midwifery officer Sue Hayward, have moved through a process of reviewing, streamlining, developing and testing to find the optimal outcome.

“A tangible result is the reduction of nursing assessment forms from 60 to 2 forms, plus an expanded flipchart of assessment tools for different patient conditions,” says Melody Mitchell.

“The more important intangible result is the breakdown of nursing “silos” and changes in nursing practice.”

She says this was done by engaging with staff in developing an assessment process that is more focused on what matters to the patient.

“It challenges nurses to work in a different way. The testing of the new approach was really important, because nurses needed to feel challenged and then to feel the relief that they no longer had to do things the way they always have. They don’t have to feel the burden of so many forms. The whole process of assessment shifts from being a form-filling exercise to being a patient-centred discussion.

Michele says they have received really positive feedback from nurses and patients, as well as from healthcare assistants who want to become involved in the process.

It also brings all the different specialties that nurses work in, the different wards and nursing settings, onto the same page – or in this case, onto two key forms.

“There just two forms now that are common across all the specialties,” she explains. One is for the patient to complete so we get quality information about the context of their health and what is important to them. We call that the subjective assessment form. The other form is for nurses to complete, the objective assessment. The flip chart helps them with advice on how to assess different conditions, and that replaces all those other specialty forms in one easy-to-use toolkit.”

Sue Hayward says the implementation will help nurses view documentation as being an essential component of their work, supporting patient care rather than being non-value-added “paper work”.

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