We have switched to a hospital wide EMR with EPIC. Multiple documentation tabs are available including careplans,flowsheets, screening assessments,patient education and notes. The issue we have is lack of standard policies as to what is appropriate documentation for repeat patients. (I am at an outpatient wound care center.) What screenings are required, how frequently do care plans need to be updated, and nurses not writing a note when the provider sees patient are some of our concerns. Nursing documentation seems not to trigger any alerts - a poor score on a braden scale or a yes on an anticoagulant question doesnt set off any triggers.
We are interested in setting standards across ambulatory care areas, slowly we are getting by-in from administration.
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Lauren Leimbach BSN, RN, CWCA
Centrastate Med Ctr
Morganville NJ
(732)610-4583
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Original Message:
Sent: 08-11-2023 10:43
From: Justine Alipio
Subject: Ambulatory Documentation Practices
Good morning AAACN,
Are there any organizations that have special documentation practices for their Ambulatory RNs? For example, is documentation mostly being done in notes or does anyone have flowsheets built out, are nurses documenting care plans or patient education?
| Justine K. Alipio, BSN, RN, CCRN Ambulatory Clinical Practice Consultant RUSH | RUSH University Medical Group 1750 W Harrison Street | 720 Pavilion | Chicago, IL 60612 
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