Background: At a large academic medical center with over 80 clinics, variations in documentation procedures can inadvertently lead to clinical staff working outside of their role boundaries. In one such instance, providers in a procedural clinic were attempting to delegate verbal orders to nurses via a third-party clinical staff member. To ensure that nurses operated within their appropriate scope in this and similar circumstances, a work group was developed to review variations in documentation for procedural medications. Nurses reported to the work group that they felt uncomfortable placing medication orders and documenting the administration for the surgeons despite not witnessing the procedure. The nurses identified that this was not best practice, being that the athletic trainers were the ones assisting with the procedure. Therefore, the work group was tasked with empowering the athletic trainers with the appropriate tools to document the medication administration while still operating within their scope of service.

Objective/purpose: Procedure narrator tool would allow the athletic trainer to document real-time medication ordering and administration. This would prevent the nurse from being asked to place an order or document an administration that they did not witness.

Design/methods: A multidisciplinary work group was created consisting of members from the billing department, information resources, nursing operations, and pharmacy. Information was gathered regarding medications, procedure workflows, and documentation requirements. A demonstration was presented to clinic leadership, provider champion, and athletic trainers. Training consisted of an in-service, tip sheets, and access to the training environment to preview the tool and solicit feedback prior to go-live.

Results/summary: A post implementation survey was sent to the impacted staff members, namely nurses, and athletic trainers. Using a five-point Likert scale, the target respondents were asked: 1) Prior to procedure narrator: Best practice was being followed when the nurse placed the ortho medication order. 2) Prior to procedure narrator: Best practice was being followed when the nurse documented the medication administration with use of the ortho medication handoff form. 3) Post-procedure narrator go-live: Best practice is being applied when the athletic trainer documents the one-step med for the provider. 4) Post-procedure narrator go-live: Best practice is being applied when the athletic trainer documents in the MAR (medication administration record) for the provider while in the room. 5) On a scale from 1-5, how likely are you to recommend the procedure narrator tool?
Overall feedback reviewed was positive, respondents overwhelmingly agreed that they would recommend the procedure narrator tool.

Lessons learned: Respondents were also given the option to provide comments. Comments were mostly neutral; however based on the answers, workflow enhancements were implemented to include items such as billing details and administration site documentation.

Conclusion/outcome: After successful implementation at the procedural clinic, the work group is identifying other clinics that could benefit from the procedure narrator that also have variations in documentation of procedures.

Erika Lopez BSN, RN

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