Lynn Timm, RN, C, and JoAnn Johnson, RN, C, IBCLC, clinical educators in the special care nursery at Children’s – Minneapolis, faced a challenge that is becoming familiar to nurses across the country: ensuring that electronic documentation systems offer the tools and processes that nurses need to do their jobs well.

“This project grew out of necessity when the electronic medical record was implemented in the Level II special care nursery,” says Johnson. While electronic nursing care plans existed for adult and pediatric patients, there were none available for neonatal patients.

Fortunately, the special care nursery did have a useful and well-designed paper-based nursing plan of care, which Johnson and Timm had helped to create years earlier. It incorporated the North American Nursing Diagnosis Association (NANDA) language, a standardized taxonomy that classifies actual and potential health problems, and served as their starting point.

To provide a comprehensive description of the nursing process, Timm and Johnson updated the existing care plan and also incorporated two other standard language taxonomies: Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC). After months of study, comparison, and review, the electronic care plan was implemented earlier this year.

In addition to helping nurses plan, assess, and evaluate the care they provide, the new electronic nursing care plan is based on clinical studies and supports the use of evidence-based practices. It will also be an important tool for conducting research. “You can pull the data based on certain interventions, length of stay, complications, or other indicators.  The software has many capabilities,” says Timm.

“We were excited to develop a nursing care plan that will work for us in the electronic world,” says Johnson. “We know it will take some time for staff to incorporate this into their nursing care, but we’ve gotten a good reception so far. This is a care plan that really works.”