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Keywords:

  • perinatal computerized documentation;
  • OB documentation systems;
  • change theory

Poster Presentation

  1. Top of page
  2. Poster Presentation

Purpose for the Program

An integrated perinatal computerized documentation system.

Proposed Change

The proposed change was moving from a stand-alone labor and delivery computerized documentation system (including fetal monitoring) to an integrated perinatal computerized system. This system is accessible throughout the institution and remotely. It is integrated with the institution's mainframe computerized documentation.

Implementation, Outcomes, and Evaluation

Implementation of the computerized documentation was completed in several phases, starting with the postpartum unit, the normal newborn nursery, and the neonatal intensive care nursery. Labor and delivery went live with the antepartum and intrapartum piece, whereas the computerized fetal monitoring was the last to be implemented. Outcomes include the benefit of the entire perinatal system being able to view the maternal and newborn delivery data in one system, as opposed to the hybrid system that existed prior. The fetal monitoring surveillance is now available in several areas across the institution: the emergency department, intensive care unit, and main operating room. An anticipated outcome is the ability to pull reports from the data documentation. This has so far included types of birth, use of provider order sets, audits of nursing documentation, and capturing delivery elements.

Implications for Nursing Practice

Implications for nursing practice include ease of reviewing data and capturing data for reports and the potential for earlier recognition of patient abnormal values, thus increasing quality patient care.