Creating a system of Documentation Objectives: 1. To understand and overcome the barriers that hinder compliance with implementation of a stoke protocol set 2. Obtaining and maintaining staff competency for stroke protocol at a rural/critical access hospital

Goals of a Good Documentation System  Improved treatment and care of the stroke patient  Improved and interactive communication between physician, staff, and patients and their families  Assists with any quality improvement process related to stroke care

Documentation should include…..  Use of Stroke order/protocol sets that include Orders Protocols for stroke patients Patient and family education information Physician checklist Patient discharge instruction forms or Transfer form

Barriers  Physician or staff unwilling to use/follow protocols  Poor communication or interaction with a tertiary stroke hospital  Nursing staff unwilling to use/follow protocols  Poor documentation

How do we overcome documentation deficiencies?  Physician champion  Nursing champion  Ease of use and clarity of protocols or forms  Good communications with tertiary hospital stroke center  Staff education (and ongoing re-education)  Willingness to revise protocols and forms to meet best practice and assist with documentation.  Front-line staff involvement in the process (from protocols to revisions and process changes to enhance care)  Work with tertiary stroke hospital to best meet the patient’s needs and documentation requirements

Contact with a tertiary stroke hospital  ED Medical Director establish a relationship with neurosurgeon at tertiary stroke hospital  Obtain their protocol and documentation forms  Mirror your protocols and forms to reflect similar protocols and documentation forms

GWTG benefits  Graphical illustrations for immediate feedback and to share with physicians, committees and nursing  Use collected data information for other quality processes  Educational material for print out  Physician and patient letter printout capability  All of the above assist with improved processes and benchmarking

References: Please refer to:  AM, HF & PN protocols implemented by Dunn Memorial Hospital  Discharge Instruction Form  Physician checklist

Thank You Donna Sexton RN Performance Improvement Manager Dunn Memorial Hospital Bedford, Indiana