After 8 weeks of training for all clinical staff, MidState Medical Center went "live" with Knowledge-Based Charting, or KBC, last month. All inpatient pavilion healthcare teams initiated this new method of clinical documentation as part of the hospital’s next step in going “paperless.”

The most striking advantage of KBC is that all of the information surrounding the patient’s visit and condition can be entered electronically by each member of the inter-disciplinary team. Team members carry a portable device room-to-room, which makes charting convenient and efficient for staff because patient documentation is no longer centralized in one tangible binder.

“Our staff was so prepared for this change. Their practicing with test patients from home or on duty as time permitted was apparent. It was hard to slow them down. The managers prepared each unit with additional staff so the "super-users" would be available to assist their coworker as we transitioned patients from paper to the new automated program,” said Claudette Genova, Director of Clinical Informatics.

Another unique feature of the KBC system is the patient profile, a comprehensive overview of the patient’s condition and lifestyle that can be recorded and saved. The patient’s profile not only takes into account medical and family history, but also religious beliefs and social history. It is truly holistic in nature.

KBC revolutionizes point-of-care decision-making by offering seamless integration of embedded content within the context of individualized patient information. This innovative solution is designed to prevent or manage potential patient complications and facilitate collaboration among healthcare workers. It supports all levels of clinical expertise, providing the framework to standardize evidence-based documentation and practice across the care continuum. KBC gives the healthcare team instant access to more than 180 evidence-based Clinical Practice Guidelines.

Other key benefits include:

• Improves quality and completeness of documentation
• Encourages critical thinking and outcomes-focused care
• Enhances patient safety by identifying potential patient complications
• Reduces practice variability and promotes interdisciplinary collaboration
• Streamlines compliance with Joint Commission and other regulations

As Claudette put it, “This type of document is wonderful for the management of patient care.”