Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.
Beginning Dec. 3, 2013:
Internal Medicine -
General Surgery “Baker” -
General Pediatric -
Oncology (limited) -
Respiratory Therapy -
Case Management -
Spiritual Care -
Occupational Therapy (LMR) -
Physical Therapy (LMR) -
Speech Language Pathology (LMR) -
Social Services (LMR)
Remaining users and documentation including Nursing Notes will be implemented over the next several months as we continue our phased rollout approach.
In the spring of 2016, MGH will “go live” with Partners eCare, a new common electronic health record (EHR) system that will allow medical record sharing in real time. Partners eCare is being introduced Partnerswide and will span inpatient, outpatient, ambulatory, surgery, emergency, billing, scheduling, and patient portal activity.
The hospital’s “eBridge” initiative—being rolled out to clinical staff Dec. 3, 2013 —is designed to help prepare the MGH community for this move to Partners eCare. This “bridge” to Partners eCare involves the electronic notes documentation software for nurses, physicians and other health professionals. For Nursing, eBridge involves the use of a template that is specifically designed to structure a plan of care concept along with the progress note. Ultimately, Partners eCare will employ a structured plan of care activity that will support a problem-oriented charting style. The Nursing template in eBridge begins the transition to this problem-oriented charting style, while communicating a plan of care for the patient and reflecting the nurse’s assessment on the patient’s progress. Once the clinical aspects of Partners eCare are up and running, eBridge will be phased out.
Planning for Care
Introduction to Standard PC.01.03.01
Planning for care, treatment, and services is individualized to meet the patient’s unique needs. The first step in the process includes creating an initial plan for care, treatment, and services that is appropriate to the patient’s specific assessed needs. To continue to meet the patient’s unique needs, the plan is maintained and revised based on the patient’s response. The plan may be modified or terminated based on reassessment; the patient’s need for further care, treatment, and services; or the patient’s achievement of goals. The modification of the plan for care, treatment, and services may result in planning for the patient’s transfer to another setting or discharge.
The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2)
The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals. Note: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The patient’s goals include both short- and long-term goals.
22 Based on the goals established in the patient’s plan of care, staff evaluate the patient’s progress.
23 The hospital revises plans and goals for care, treatment, and services based on the patient’s needs. (See also RC.02.01.01, EP 2)
(Taken from 2014 Joint Commission Comprehensive Accreditation Manual)
American Nurses Credentialing Center (ANCC)
The true essence of a Magnet organization stems from exemplary professional practice within nursing. This entails a comprehensive understanding of the role of nursing; the application of that role with patients, families, communities, and the interdisciplinary team; and the application of new knowledge and evidence. Exquisite documentation in the patient record is key in communicating the patient’s plan of care.
There are numerous terms and acronyms in healthcare that may be unfamiliar. Please click here to visit a Glossary of Terms that may be helpful. And please email any suggested additions.
This month's featured term: Electronic Health Records
The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. (From HIMSS http://www.himss.org/library/ehr/?navItemNumber=17633)
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Excellence Every Day represents an MGH commitment to providing the
safest care that meets or exceeds all standards
set by the hospital and external organizations.
If you have questions or suggestions related to the EED portal, please contact Georgia Peirce at (617) 724-9865 or via email at firstname.lastname@example.org.