Abstract P830: Using a Nurse Tasklist in an Electronic Medical Record to Achieve Compliance With Documentation of Post Procedure Assessments

Background: For stroke centers performing endovascular procedures, ensuring documentation of post procedure assessments - site and pulse - is not only important for patient safety but also for program certification. Not being able to demonstrate the appropriate documentation during certification site visits can lead to survey findings and action plans that must be created and managed. Use of tools in an EMR can assist the nurse with documentation compliance for these important assessments. Methods: The electronic medical record (EMR) build was mirrored after an already established process for post IV thrombolytic monitoring. When the thrombolytic order set is initiated and the IV thrombolytic medication is documented on the medication administration record, tasks “fire” to the nurse tasklist related to post thrombolytic monitoring for the 24 hour post IV monitoring period. The nurse can select the task on the tasklist and it takes the nurse to the appropriate place to document as well as at the appropriate time to document. Use of this process helped to drive compliance with post IV thrombolytic monitoring documentation. In order to achieve compliance for post procedure assessments documentation, this same process was requested by nursing. To achieve this, the EMR was designed to “fire” tasks to the nurse tasklist when the post thrombectomy order set is initiated and the time hemostasis is achieved is documented; these tasks cover the post thrombectomy monitoring for the required 24 hours. Part of these tasks include post procedure assessments. Results: From May 2019 to October 2019 the average monthly compliance for post procedure assessments was 77.6%. In November 2019, the appropriate tasking function was implemented in the EMR and education related to the new process was provided. From December 2019 to May 2020 average monthly compliance has been 91.1% with a monthly compliance rate greater than 90% since February 2020. Conclusions: Use of the nurse tasklist in an electronic medical can assist the nurse with documentation of post procedure assessments and achieve documentation compliance.