Care Planning
Paper to Electronic
Mary Clarke – RGN
Inpatient Nurse Manager
Kate Sant – RGN
Project Clinical Secondee
How it all began
• 2009 agreement to be care planning
early adopter
• March 2010 invited to CAG
• September 2010 Clinical Secondee
appointed
• Go Live date set for January 2011
What we had
PATIENT CARE PLAN
Patient Problem
……………………………………… has been admitted for surgery and is
unprepared for the procedure
PATIENT CARE PLAN
Patient Problem
……………………………………… has reduced mobility, and is therefore at
risk of chest infection, DVT, PE, constipation, pressure sores etc
Aim
Aim
To ensure patient is well prepared physically and psychologically
To prepare safely for surgery as per Hospital Policy
For the patient to be free of complications
Detect complications early if they do arise
Treat Effectively
Resume as much mobility as possible
To ensure awareness of Manual Handling Policy
Nursing Management and Action
Nursing Management and Action
Orientate and welcome to ward
Explain all procedures and allow time for questions
Advise patient to change her position every 2 hours (note manual handling policy). Observe
pressure areas regularly (initially every 2 hours, and once mobile each shift)
Monitor and record Waterlow score and use appropriate mattress
Encourage deep breathing and leg exercises
Monitor and record baseline observations, and waterlow score
Refer to physiotherapist as appropriate
Measure and provide anti – embolic stockings if required (NB Do not use stockings if the
correct size is not available, of if there are ulcerated areas on her legs or feet)
Measure and fit anti embolic stockings
Ensure consent forms are signed
Give prescribed anti coagulant
Give prescribe bowel preparation or if patient is constipated offer suppositories
Advise to follow a high fibre diet, and encourage a good fluid intake
Encourage early mobility as able
Patients for operation should have top shave performed as close to theatre as possible
Patient should have nothing to eat or drink as per consultant request
Observe any sputum, and observe for chest pain, or breathlesness. Note any calf pain, redness,
tenderness, or swelling
Pre Anaesthetic checklist completed
Report any complications to medical staff promptly
Date Commenced…………………..…………
Date Resolved ………………………………
Nurse Signature ………………………………
Nurse Signature ……………………………..
Date Commenced…………………..…………
Date Resolved ………………………………
Nurse Signature ………………………………
Nurse Signature ……………………………..
New paper
Test Patient
Test Patient
Test Patient
Test Patient
Test Patient
Test Patient
Test Patient
Test Patient
Test Patient
What went well
• More comprehensive and up to date care
plans using standardised content from
NHS Connecting for Health Library
• Staff more involved in the development of
the care plans therefore more consistency
in patient care
• Piloting of paper version invaluable
• Excellent training and support from team
• Better accessibility to computers
What could have been
better
• Timing from pre-op go live to wards.
• Training took place too early and
refresher training not mandatory
• Did not recognise staff needed basic
IT skills
• More support post go live
Lessons learnt
• Early Involvement of Clinical staff
• Importance of Paper pilot
• Consideration of Business process/patient
pathway
• Clinical staff involved with testing
• More Senior Management level involvement
• Dedicated IT support
• Ongoing floor walking support
• Equipment:Computers
Infection control
Storage
Security
Ongoing benefits
• Auditing
• Record keeping
• Comprehensive records
• Version control
• Less paper
Next steps
• Discharge letters.
• Referral letters.
• Coding.
Further Information
• Birmingham Women’s Hospital
Electronic Care Planning Project contact:
Mary Clarke, Inpatient Nurse Manager, Gynaecology,
Birmingham Women's NHS Foundation Trust
Email: mary.clarke@bwhct.nhs.uk
• NHS Library Care Plan Content
NHS Care Plan Content project contact:
Su Wilkinson, Strategic Alignment Lead, NHS Connecting for Health
Email: knowledgeandstrategicallignment@nhs.net
Access NHS Library of Care Plan Content (technical view) registration
is free for NHS or SNOMED CT licence holders - download the Care
Planning pack - Via:
http://www.uktcregistration.nss.cfh.nhs.uk/trud3/user/guest/group/0
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Questions