SINI 2024: Ambulatory Intake Requirements
Authors
Massey, Amber ; Boland, Mollie
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Abstract
There was not a clearly defined minimum expectation for documentation of clinic intake. Different areas prioritized different items for their patient populations with variations even between staff members in the same department. This resulted in an inconsistent experience for our patients and confusion for our staff and providers. To address this issue, Vanderbilt Nursing Informatics Services worked closely with Quality and Safety to define minimum standards and develop a tool for all ambulatory spaces to help guide staff through those questions that formed the minimum standards. Working with the Ambulatory Analyst team to develop a checklist that displays in the Intake activity within eStar. It displays the organizational minimum requirements, and once a staff member addresses that item, it is checked off the list. Additionally, the checklist is smart enough to know if an item has been addressed in the past. This allowed us to make some requirements due annually and satisfy the checklist if the item had been performed in the last 365 days. This helped reduce the number of questions asked to patients and crossed encounter departments. For example, if you had been asked in Primary Care about your advanced directive last month, you wouldn't be asked again in ENT today. We launched this project in all ambulatory areas at once! It was such an intuitive design that staff required very little at-the-elbow support. The checklist helped guide them through the minimum requirements as designed. Overall, we achieved the outcome of defining the core minimum intake requirements and developing a tool to encourage adherence to the new standards. Also, staff reports an increased ability to determine the required documentation for ambulatory encounters since the change was implemented. Through a multi-team approach, we were able to improve nursing workflow and patient satisfaction by helping to define minimum documentation standards that meet regulatory requirements and satisfy quality standards.
