Use of Standardized Nursing Languages in the Documentation of Renal Dialysis Services

BACKGROUND

Renal dialysis at our institution is a unique specialty area that provides both nursing care for a stable chronic outpatient population and treatment for hospitalized patients with acute episodes of renal failure. The ability to respond to these patients' special needs is inherent in delivering nursing care and must be comprehensively and consistently documented. The purchased computerized documentation system did not have any experience with online renal dialysis documentation. Since the institution was using an electronic patient record, we decided to blend the move to electronic documentation with the use of standardized languages to describe dialysis care.

MAIN CONTENT POINTS

A review of existing standardized nursing language materials revealed that the necessary interventions and outcomes were not available, so leadership and staff collaborated to produce new interventions and outcomes specific to the dialysis population. These interventions and outcomes were submitted to NIC and NOC for approval. The existing care plans were converted to standardized nursing language and the implementation process begun. All existing dialysis documentation and data collection forms were examined, grouped, and converted to NANDA, NIC, and NOC terminologies. Standardized languages were incrementally introduced as the electronic record was put into use. First the basic patient information and medication list were used in the “live” setting, while documentation was still done on paper.

The care plan, which incorporated standardized language, was introduced next. The standard dialysis care plan included 8 nursing diagnoses, 14 outcomes, and 26 interventions. Finally, the interventions and outcomes were used in the actual documentation of treatment parameters and patient data. Also available are all the outcomes in the inpatient dictionary, which can be used to individualize the care plan as needed. Use of the computer allayed staff fears of having to “memorize the books” to learn all the components of the standardized nursing language.

Interdisciplinary aspects of care were addressed by assisting nutrition services, social work, and the chaplaincy to find appropriate interventions and outcomes in the standardized language. Documentation screens then developed for each discipline contributed to the overall integrity of the record. Regardless of discipline, documentation occurs in a standardized, logical, and retrievable way. Measurement of outcomes makes tracking the course of each patient, as well as the cohort, possible. Pertinent documentation elements are displayed on a patient profile to provide individual treatment records.

CONCLUSIONS

NANDA, NIC, and NOC are extremely useful in the care of the dialysis patient. Because particular interventions are used repeatedly, the electronic format and standard responses give a consistency to patient evaluation not present previously. Use of electronic documentation eased the transition to the use of standardized nursing language by presenting standardized documentation responses for each intervention. Outcomes documentation was enhanced by clear definition and quick access to ranking criteria.

Outcomes of this project include (a) enhanced communication between inpatient and outpatient dialysis services, (b) ability to immediately access information about patients treated at satellite dialysis units, (c) ability to measure outcomes over time for the aggregate and for individuals, and (d) staff satisfaction with documentation.