International Journal of Nursing Terminologies and Classifications Implementation of Standardized Nomenclature in the Electronic Medical Recordijnt_1132 169..180 Joan Klehr, RNC MPH, Jennifer Hafner, RN, BSN, PCCN, TNCC, Leah Mylrea Spelz, RNC, BSN, ACCE, Sara Steen, RN, BSN, TNCC, and Kathy Weaver, RNC, BSN PURPOSE. To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. DATA SOURCES. Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. CONCLUSIONS AND IMPLICATIONS. Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation. Search terms: Care plan, electronic medical record, Epic, NANDA-I, NIC, NOC, nursing taxonomy, standardized nomenclature doi: 10.1111/j.1744-618X.2009.01132.x Joan Klehr, RNC, MPH, is an information systems analyst; Jennifer Hafner, RN, BSN, PCCN, TNCC, and Sara Steen RN, BSN, TNCC are staff nurses at the Medical/Surgical Intensive Care Unit; and Leah Mylrea Spelz RNC, BSN, ACCE, and Kathy Weaver RNC, BSN, are staff nurses at the New Beginnings Birthing Center, of Aspirus Wausau Hospital, Wausau, Wisconsin Aspirus Wausau Hospital installed Epic as the new clinical information system (electronic medical record) in December 2003. Epic is a nationally recognized electronic medical record vendor for both inpatient and outpatient documentation. It replaced the old legacy system and provided electronic documentation of clinical information, including care planning, for the organization. The care plan activity provided by Epic is master file driven and requires standardization of language for nursing care plans. The staff was no longer able to create problems, goals (expected outcomes), and interventions by entering free text data. However, the records do include a free text description field where a user can individualize the care plan based on a patient s particular needs or status. A decision was required regarding whether clinical experts and system administrators would work together to create organization-specific problems, goals, and interventions, or the organization could pursue the use of a third party product such as Snomed CT, NANDA-I, Nursing Outcome Classifications (NOC), or Nursing Intervention Classifications (NIC). Refer to Figure 1 for a schematic of the Epic care plan master file layout. A literature review was completed and it was decided that a third party product would be purchased. A presentation was made to the Nursing Professional Practice Committee with a recommendation to pursue the use of Snomed CT because it provided nursing terminology and terminology used by other disciplines such as psychiatry, therapy departments, and others. International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 169
Implementation of Standardized Nomenclature in the Electronic Medical Record Figure 1. Epic Care Plan Masterfile Schematic. NIC, Nursing Interventions Classification; NOC, Nursing Outcomes Classification There was an almost immediate roadblock with the use of Snomed CT at the time Aspirus was ready to complete the implementation. Snomed CT was not available in an electronic format and could not be imported into Epic s master files. Because of this, the organization proceeded to procure contract and license agreements to use NIC, NOC, and NANDA-I for the care plan master files. These nursing terms would be used for other disciplines where appropriate. Epic system administrators then handbuilt any problems, goals, or interventions that did not fit with the available nursing terminology. There was also an issue with nonnursing disciplines feeling that they were being Forced to use nursing language for their specialties. Once the decision had been made to pursue the use of NIC, NOC, and NANDA-I, the actual designing and building of the care plans were begun. The design team determined that staff would use pre-built care plan templates wherever possible. A care plan template consists of a set of related problems, goals, and 170 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009
Figure 2. Care Plan Design December 2003 interventions. Epic s care plan product does allow for manual creation of care plan problems at the bedside. However, users must use the problems imported into the master file records, and the creation of those care plans is a somewhat laborious task. There would also be no method of assuring that the care plans built in the moment were created using the new design format. A paper template was developed to assist clinical subject matter experts (SME, staff nurses) design the templates using the correct format. They were invited to join together to develop care plans for their specialty areas. Textbook resources were made available to assist with the design of the templates including the current versions of NANDA-I (NANDA-I, 2003), and the Nursing Diagnoses, Outcomes, & Interventions: NANDA-I, NOC, and NIC Linkages (Johnson et al., 2001). NOC Second Edition (Moorhead, Johnson, & Maas, 2004) and NIC Third Edition (McCloskey Dochterman & Bulechek, 2004) were available in the medical library; however, they were not given to the units to assist in the build. Design decisions were required, as the Epic care plan format did not readily adapt to the NOC rating scales or inclusion of the NIC activities. A recommendation was made and accepted to use only the NIC labels for the care plan interventions. NOC labels were entered as the care plan goal; however, the rating scales were not included. Epic includes a detailed field that users can free text for information. The SMEs created measurable goal statements for each NOC label created. Refer to Figure 2 for an example of the care plan design. Issues with the Initial Care Plan Build (2003) There were several key issues with the care plan project. The biggest issue was related to knowledge deficit regarding the use of standardized nomenclature. The vast majority of the nursing staff had never been exposed to NANDA-I, NIC, or NOC. The average age of nurses at the hospital is 41. Many of them completed their nursing education in the 1970s and 1980s. The training programs did not include exposure to standardized terminology as they were not readily available when those nurses completed their core nursing programs. Although staff was trained in the functionality of Epic, the foundations of the standardized nomenclature were not emphasized in the training. Refer to Appendix A for one department s perspective of the change. The NOC labels were not being used as designed when the Epic care plans were first implemented. NOC rating scales were not included in the build, partially because the program did not have a field to International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 171
Implementation of Standardized Nomenclature in the Electronic Medical Record accommodate the rating scale, but largely due to lack of understanding as to how the rating scales worked. The team was concerned that accrediting bodies would not find a Likert scale measurable. Feedback indicated that the organization implemented too much change too quickly. The care plan build was an entirely new workflow for many of the professional clinical staff. Many were not accustomed to working with computers. Asking them to use a computer to complete their care plans in addition to learning new taxonomies was therefore overwhelming. Practice was not monitored after the new product was implemented; therefore, nurses and other professionals were not provided with timely feedback. This lack of feedback prevented improvement of care plan documentation and correction of problematic habits. The method used to name the care plan templates became a barrier to use. The care plan templates were named with a prefix consisting of the department from which the template originated or where the patient population was normally housed. This was done to assist users in finding the templates for their patient populations more easily. Practitioners mistook this as a restriction as to which care plans they could use even though the care plans were very appropriate for their patients. Instead, staff created new hand written care plans. Practice Council Re-evaluation of Usage of NANDA-I, NIC, and NOC In late 2004, Aspirus hired a firm to perform a mock survey of the facility to prepare for a Joint Commission survey visit. One finding reported that care plan goals were not measurable and did not include definite time frames. They were standardized with little individualization and were not reflective of revisions as the result of changes in patient needs. The Hospital-Wide Practice Council created a preliminary task force and representatives from each unit went to a care planning refresher course. The attendees of the refresher course were to disseminate the information to the rest of the staff. The lack of compliance with care planning documentation continued. The Hospital-Wide Practice Council continued to focus on care planning from 2005 to 2006. The council wanted to develop nomenclature and care plan templates that would be consistently used by nursing staff. A staff nurse performed a literature review in fall 2005 to identify the most appropriate nursing nomenclature for Aspirus. She determined that the most comprehensive and widely used nomenclatures were NANDA-I, NIC, and NOC. Based on this, the Hospital- Wide Practice Council chartered another task force to review the languages, revise the templates, and create new care plans. Team Created The Care Plan Task Force was created in November 2005. The task force was charged to review, update, and improve the care plan documentation process at Aspirus. Volunteers for the committee consisted mostly of staff nurses who had an interest in the care planning process. The task force also included two clinical nurse specialists who had experience with NANDA-I, NIC, and NOC, a staff member from the Information Technology (IT) department, a staff member from the Educational Services department, and two members from the Hospital-Wide Education Council. Early Plans The initial task force meeting was held on November 2, 2005. The first step was to identify problems with the care plans and familiarize members with NANDA-I, NOC, and NIC. The next steps consisted of identifying the most frequent patient admission diagnoses in this hospital, evaluating the care plan documentation, and assessing the care planning needs. The electronic care planning system was not 172 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009
complete, the templates were outdated and were not being used correctly by staff due lack of education, and there was general non-compliance. Many new care plans were needed to modernize the documentation. The task force recognized the importance of staff education as illustrated by inconsistent care plan documentation and the incorrect use of the standardized nomenclature since the inception of the electronic care plan at Aspirus. The vice president/chief nursing officer joined in the efforts to redesign the entire process, and continues to do so. Bringing in the Experts A member of the care plan task force attended Bellin College of Nursing in Green Bay, WI, which was one of the first nursing schools to incorporate NANDA-I, NIC, and NOC into their curriculum. A faculty person, a nationally known expert in the NANDA-I, NIC, and NOC standardized nomenclature, was consulted to work with the project. The task was to assist with reviewing and revising the current care plans and new ones that were to be developed by the nursing staff. She recruited a colleague, the president-elect of NANDA-I who has a degree in nursing informatics, who provided consultation to assist with the implementation of the new care plans into Epic. She assisted the team in developing a method to incorporate the NOC Likert scales into the build. An introductory meeting was held at which time the consultants made a recommendation that several members of the project team attend the 2006 NANDA-I, NIC, NOC Conference in Philadelphia, PA. The theme of the conference was Electronic Use of Clinical Nursing Data. Three members of the project team were provided with approval to attend. The 3-day conference allowed for an in-depth immersion into the world of NANDA-I, NIC, and NOC. Conference sessions included general sessions covering topics such as economic evaluations of the use of standardized terminology, future horizons for NANDA-I, NIC, and NOC, and smaller breakout sessions which focused on implementation projects that used standardized nomenclature including academic centers as well as healthcare settings from outside of the United States. The knowledge and networking gained from the conference were utilized in the design of the new care plan build. Funding the Project Funds were originally unavailable for the small project that would turn out to be an enormous, ongoing process. The Vice President, Chief Nursing Officer provided financial and organizational support to the taskforce. In addition to sending members to the conference in Philadelphia and hiring the consultants, new resources were purchased and a workshop was planned. Working with Epic The IT staff and members of the task force met with the consultant to devise a format for displaying the care plan goal details in Epic prior to the workshop. Adaptations were made to the care plan activity in Epic to create a user-friendly format for editing and individualizing the outcomes. The templates were designed to allow retrieval of data for reporting purposes and any future research which may be completed using the care plan. The detail fields used to add the NOC indicator and rating scale information were not discrete data fields. A discrete data field has coded values. In lieu of entering free text information, a nurse chooses from a list of data elements, i.e., an item from a pre-built list. A workaround for this was accomplished by use of Epic s discrete smart list functionality. Use of these records allows data to be electronically pulled from a paragraph of text. A recent upgrade of the Epic system allows for a new discrete field for rating patient progress toward meeting the target outcome score. This new discrete field will allow for a more efficient method of accessing data. International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 173
Implementation of Standardized Nomenclature in the Electronic Medical Record Resources for the Workshop Resources selected were the NANDA-I classification book (NANDA-I, 2005) and a nursing diagnosis handbook (Ackley & Ladwig, 2006). One to two sets of resources were purchased for each of the teams: the nursing unit, the educational services, and the IT department. The nursing diagnosis handbook was a good resource for searching for NANDA-I diagnoses appropriate for illnesses and diseases. However, the book had some paraphrases and a limited index of NOC indicators. The book also omitted some defining characteristics of the NANDA-I diagnoses. These limitations provided an obstacle to the abilities of the workshop participants to create the new care plans. The participants used the four copies of NIC and NOC reference books during the workshop to complete the care plans created that day. Additional NIC and NOC references were purchased after the workshop to use for later completion of the care plans. Workshop The Care Plan Task Force hosted a 1-day training workshop to educate clinical SMEs on NANDA-I, NIC, and NOC. The workshop started in the morning with a lecture on the nomenclature and its application to documentation. Case studies were reviewed and staff began creating care plans in the afternoon. Nurses familiar with the nomenclature provided assistance to the nurses creating the care plans. Meeting with the Units There was insufficient time during the workshop to complete all the necessary care plans. Therefore, the chair of the task force met with SMEs from each unit with the exception of two, to create care plans that were not completed at the workshop. Four nursing units had additional work sessions to finish the necessary development of care plans. Review of Care Plans The care plans which had been created and revised were sent to one of the consultants for review to ensure proper use of the nomenclature. The care plans were then returned to the Care Plan Task force for final approval. This was to ensure that the care plans would appropriately reflect nursing practice at this facility. More than 140 care plans were either created or revised by the task force and staff nurses. The approved care plans were then submitted to the IT department to be built into Epic. Following the Epic build, the group again reviewed the care plans to check for content and spelling errors to ensure accuracy within the project. Errors such as missing NOC indicators and typographic errors were found and corrected immediately; however, not all errors were found. Additional errors were made during the move from the test environment to the production (live) environment. There was no programmatic method to move care plan templates from the test environment to the production environment. Therefore, the care plans had to be rebuilt manually during the go-live by staff. A second review was required after the go-live to check for spelling and other errors and to ensure a professional product. Errors were again found and corrected immediately. The Build The new care plan format used the previously mentioned description fields to display the label definition for the NANDA-I and the NOC. To use NOC as it was designed, users needed to determine the proper indicators, assign an NOC rating at initiation and target NOC rating. Drop-down lists were created to include a selection of the most commonly used indicators for each NOC and the corresponding rating scales. Nurses selected the most appropriate indicators for the patient. If the indicators were not applicable, the nurse would add additional indicators from the NOC reference book. NIC interventions were assigned to each 174 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009
Figure 3. Care Plan Design December 2006. NOC, Nursing Outcomes Classification outcome as appropriate. NIC definitions were not included on the intervention detail unless the authoring SME decided further description was required. Refer to Figure 3 for the new care plan design. Figure 4 represents the care plan design after the June 2007 Epic upgrade. NANDA-I, NIC, and NOC did not completely meet the hospitalized patient s care plan needs. In addition, some diagnoses and outcomes that were appropriate for the hospitalized patient needed revisions to reflect current practice. New diagnoses and outcomes were developed, and revisions were submitted to the NANDA-I Diagnosis and Development Committee (DDC) committee as appropriate. Diagnoses that were written and submitted include: Ineffective Tissue Perfusion: Cellular, Electrolyte Imbalance, Risk for Maternal Fetal Distress, Hemorrhage, Increased Gastrointestinal Motility, Dysfunctional Gastrointestinal Motility, and Decreased Gastrointestinal Motility. Risk for diagnoses were also submitted for Electrolyte Imbalance, Hemorrhage, Increased Gastrointestinal Motility, Dysfunctional Gastrointestinal Motility, and Decreased Gastrointestinal Motility. In addition to the diagnoses created, the Ineffective Tissue Perfusion diagnoses were revised and submitted. Nursing outcomes written and submitted include: Tissue Perfusion: Cellular, Safe Healthcare Environment, and Neurological Status: Peripheral. Due to the naming convention used with the previous care plan design, users had a difficult time identifying care plans that were appropriate for their patients. The new templates were named based on body system, template name, or medical problem, as well as other potential naming conventions. For example, the care plan Appendectomy had two synonyms: Gastrointestinal: Appendectomy, and Surgery: Appendectomy. This allowed users to intuitively find the care plan templates they needed. The Spring 05 Epic design does not allow for a synonym to be added International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 175
Implementation of Standardized Nomenclature in the Electronic Medical Record Figure 4. Care Plan Design June 2007. NOC, Nursing Outcomes Classification to a care plan template so the build team simply created the care plans multiple times using different names but the exact same content. Staff Education Aspirus conducts a mandatory nursing in-service three times a year called the Triad. The task force held hospital-wide educational sessions for nurses to properly educate them on the use of the nomenclatures. The sessions included NANDA-I, NOC, and NIC theory to assist nurses in understanding the language. The chair of the task force presented the systematic approach to care plan organization in Epic with instructions for implementation of a care plan using the new format. The concept of the rating scales and instructions for use was explained. Interpretation of NOC indicators was clarified and discussed using a case study approach with participant involvement. The presentation was followed by a demonstration of the step-by-step process of using the care plan activity. Feedback regarding the educational program was mixed. While some nurses were excited about the changes, others did not see the value in using care plans. Some negative quotes included: This is not important to my job and This was a waste of time. These comments reflect the challenges many hospitals encounter regarding documentation and compliance. The Go-live Last minute changes were made to the display format of the outcome details. The indicators were relocated to above the NOC rating at initiation and target NOC rating because this format is more intuitive. This change pushed back the go-live date by 1 month. 176 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009
Builders were required to change the format on every outcome already built and to continue building additional care plans using the new format. In addition to issues with the transfer of care plan templates from the test to production environments, limited staff was available for assistance during the go-live. A total of seven people were available to support nurses in implementing the new care plans during the go-live week. Volunteers from the task force and Education Services rotated during the day and evening shifts to provide assistance. The decision was made not to provide support during the night shift due to lack of resources. Some staff arrived at 6:00 a.m. to assist with last minute changes to care plans for patients admitted during the night. Monitoring Compliance The task force created an audit tool to determine whether the staff was using the care plans correctly. Much of the review focused on NOC as this is where the primary changes to the nursing workflow occurred. Refer to Figure 5 for a view of the audit tool. Initial monitoring showed that the staff did well with assigning the NOC rating at initiation and setting an individualized target NOC rating. However, the staff struggled with documentation of the current NOC rating each time they charted to the outcome. This was due to the new workflow and the lack of a specific field for documenting the rating. The nurses needed to remember to enter the NOC rating using a charting shortcut called a Smart phrase. A summary of audit reports can be viewed in Figure 6. An upgrade to the Epic system in June 2007 improved compliance in this area. A field was added to the care plan activity that allowed the nurse to select the current rating from a drop down list. Conclusions Overall, the project was a success. Key factors in the success of the project included: close collaboration among staff nurses and IT staff (two of the IT staff involved in the project were nurse informaticists), ongoing support and encouragement from the Vice President/Chief Nursing Officer, the ready availability of expert resources, and nursing ownership of project. Problems that occurred in the process were quickly identified and resolved because of the said factors. Author contact: jennifro@aspirus.org References Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed.). St. Louis, MO: Mosby. Johnson, M., Bulechek, G. M., McCloskey Dochterman, J., Maas, M., & Moorhead, S. (2001). Nursing diagnoses, outcomes, & interventions NANDA, NOC, and NIC linkages. St Louis, MO: Mosby. McCloskey Dochterman, J., & Bulechek, G. M. (Eds.). (2004). Nursing interventions classification (4th ed.). St. Louis, MO: Mosby. Moorhead, S., Johnson, M., & Maas, M. (Eds.). (2004). Nursing outcomes classification (3rd ed.). St Louis, MO: Mosby. NANDA-I. (2005). Nursing diagnoses: Definitions & classification 2005 2006. Philadelphia, PA: Author. Appendix A Reactions and Responses of the Labor and Delivery Unit Staff to the Introduction of Standardized Language and Electronic Care Plans In 2003 the hospital went live with electronic documentation. All inpatient units including the labor and delivery unit started electronic documentation of assessments, medications and care plans. Care plans were moved from a paper care path to the computer based standardized language. The unit staff expressed frustration and anger about the mandated changes. The following examples illustrate the frustrations experienced and the subsequent discussions by the professional nursing staff. International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 177
Implementation of Standardized Nomenclature in the Electronic Medical Record Figure 5. Care plan Auditing Tool. NOC, Nursing Outcomes Classification Care Plan Monitoring Tool We are monitoring compliance with care plan initiation, documentation, and updates. Please select a patient and complete the following form. Unit MR# Date (month/year) Goal Statement Includes: NOC Rating At Initiation Y N NOC Target Rating Y N Expected End Date Updated Y N N/A NOC Indicators Addressed Y N Care Plan Initiated By Y N (.cpnew used when care plan opened) NOC Rating With Documentation Y N Documentation Within The First 8 Hours Y N Documentation Every 24 Hours to each outcome Y N Care Plan Reviewed Every 24 Hours (Review button checked) Y N Interventions Changed / Updated As Appropriate Y N N/A Variances Created With Change In Condition Or Goal Not Met On Discharge Y N N/A The existing care path tool was paper based but had staff ownership and investment. The nursing staff expressed frustration at the work wasted on construction and education of staff on this relatively new care plan path. Ours is a healthy population and the care paths were marked by the predictable course of postpartum infant and mother. The decision to move to care plan documentation was not unit based. Some units were permitted to use care paths. Why not ours? I thought this was a collaborative process. Concerns over original go-live include users not understanding nomenclature. Understanding the difference between progress notes, documentation flow sheets, and care plans. Unit accustomed to documenting by exception. Documenting to as opposed to just opening care plan. The resulting frustrations led to non-compliance and a determined collective response to chart the phrase, progressing towards goals on every care plan opened. This rendered the documentation 178 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009
Figure 6. Audit Results. CICU, cardiac intensive care unit; CTU, cardiac telemetry unit; MAP, medical and pediatric unit; MSICU, medical surgical intensive care unit; NBBC, New Beginnings Birthing Center; NICU, neonatal intensive care unit; OCU, oncology care unit; ORN, orthopedic neurological unit; SCU, surgical care unit 120% 100% 80% 60% 40% 20% 0% CICU CTU IMC MAP MSICU NBBC/NICU OCU ORN CICU Rehab CTU SCU IMC whousewide MAP MSICU NBBC/NICU OCU ORN Rehab SCU whousewide 120% 100% 80% 60% 40% 20% 0% 120% 100% 80% 60% 40% 20% 0% Target NOC Rating NOC Rating at Initiation CICU CTU IMC MAP MSICU NBBC/NICU OCU ORN Rehab SCU whousewide Week 1 Week 2 Week 3 Week 4 Week 1 Week 2 Week 3 Week 4 NOC rating with Documentation Week 1 Week 2 Week 3 Week 4 meaningless. Nurses and physicians reported not even reading care plans. Recognizing not only this unit s struggles but also the difficulties hospital wide, the Hospital Wide Practice Council created a task force. The charge was to do research and improve the electronic care plans using the NANDA, NIC, and NOC standardized nomenclatures. Four members of the unit were involved in this task force. The nurses who were asked to volunteer ranged from young staff familiar with the language to senior staff with limited understanding of the concepts. The leading change agent and force behind our representation to this task force was our clinical nurse specialist. During the summer and fall of 2006, work groups met on the unit level to develop care plans and create templates applicable to our practice. The work groups then took our care plans to the task force for inclusion and correction before the upgrade. This upgrade was the first time staff was required to assign initiation and target ratings and to select indicators and interventions. To forestall further resistance and to encourage ownership in the product, our unit included education about new care plan structure in our fall skills day. The focus was dedicated to the technical aspect of using the care plan product not to the language. In December of 2006, the care plan upgrade was implemented. The unit moved and adapted more smoothly but the care path mentality still prevailed. The new care plans were audited in February. Each unit was expected to address their particular issues. Our unit was identified as not opening care plans within an appropriate time frame and not documenting to each care plan opened every twenty-four hours. A mock deposition with the hospital attorney was performed and videotaped at a unit meeting to bring home the importance of complete documentation in obstetrical and neonatal nursing. In response, our unit based education chair developed a tool to walk people through the care plans and expectations. This tool was a required education assignment and had a due date. The unit based practice council voted to require documentation to the care plan at every shift. International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009 179
Implementation of Standardized Nomenclature in the Electronic Medical Record Where are we now: Confusion still exists in assigning targets to an essentially healthy population. Staff are encouraged to see patients as an at risk population. Confusion remains about charting to outcomes and not risk factors or indicators. Staff members are concerned and verbalize resistance to time spent away from bedside. Documentation during every shift is moving emphasis from care planning to progress notes. This mandate was revisited at the practice council in June 2007. Good representation on task forces; task members motivated. Creating care plans familiarized professional staff with standardized nomenclature. Challenges: Duplication of data (conceptual differences between care plans and document flow sheets). Use care plans during report. Reducing time spent at computer Appendix B Evolution of the Neonatal ICU Care Plans A new unit, the Neonatal Intensive Care Unit, was opened in February 2006. The neonate requiring this level of care usually has multi-organ problems, especially if born prematurely. Most other nursing diagnoses at Aspirus would be classified by body systems, but the need for something more multifaceted for these very small, but very complex patients was evident. To develop into a healthy, normal person, these infants now must survive in the world outside of his or her mother with the care of the interdisciplinary team of the NICU. Issues like thermoregulation, gas exchange, infection severity, nutritional status, neurological status, infant behavior, and potential impairment of parental attachment are possible complications of extrauterine transition for a neonate. The interdisciplinary team consists of neonatology, nursing, respiratory, physical, occupational, and speech therapy, as well as clinical nutrition and social services. All these disciplines needed a method of documentation to communicate with each other to successfully care for the high-risk babies. To do this, the Clinical Nurse Specialist for the Birthing Center led the initiative to bring NANDA, NIC, and NOC to the NICU as well as to the Birthing Center. In August 2006, the NICU interdisciplinary care plans needed clarification of the requirements regarding other interdisciplinary team members. Education was necessary in developing these care plans correctly. Aspirus documentation specialist was consulted to ensure proper building and implementation of interdisciplinary services documentation specific to neonatal needs. Special arrangements of care plans were considered for reimbursement of such therapies. The chairperson of the Aspirus task force, and the documentation specialist met with interdisciplinary therapies to develop care plans. A care plan titled Disorganized Infant Behavior was created for nursing, occupational therapy, and physical therapy to utilize. It was agreed to have nursing and therapies share a nursing diagnosis, with the therapies having their own outcome to document on and interventions specific to each therapy or to nursing. In addition, a care plan was created to encompass all patients of every age for occupational therapy and physical therapy. A care plan titled Ineffective Feeding Pattern specific to the NICU was also developed to collaborate nursing, clinical nutrition, and speech therapy. Social services had a care plan titled Risk for Impaired Parent-Infant Attachment, which addressed the adaptation and attachment of the parent to the infant needing long-term hospitalization. 180 International Journal of Nursing Terminologies and Classifications Volume 20, No. 4, October-December, 2009