Nursing Informatics - Electronic Nursing Documentation

Clinical documentation and practice are integrally linked – one being a reflection of the other. Collectively, allied health, nursing, and physician documentation come together to tell the patient’s story. Documentation, whether electronic or paper, must provide a record of the patient’s needs, care provided, and patient outcomes.

Electronic interdisciplinary clinical documentation will:

Create a seamless integrated database of patient care information across the continuum of care
Chronicle all aspects of care from health team members
Capture the judgment and critical thinking used in professional practice
Support UHN’s strategic goals for best practice, clinical decision making, patient safety, knowledge development and evidence-based practice
Support integrated documentation and patient centered care
Provide a corporate Documentation Standard
Support electronic structured documentation to fulfill the dependencies of the Clinical Decision Support program
Meet regulatory standards as well as organizational, government, and clinical specialty standards
Support the exchange of information between disciplines

Current Activities

Development of Patient Care Standards: These standards, created around Picker’s 8 Dimensions of Patient Centred Care, will form the foundation for the development of clinical documentation content and practice standards
Identifying documentation content requirements that reflect practice for:
- Best Practice Guidelines
- System assessments
- Symptom management assessments
- Speciality and professional practice focus assessments
Reviewing & updating UHN’s clinical documentation policy
Focus Charting - Redesigning the present unstructured narrative note method of clinical documentation to a structure focus note method