Abstract
CONTEXT: Spinal cord injury (SCI) rehabilitation nurses document the occurrence of educational and care management efforts in traditional nursing documentation methods but not the intensity (or dose) of such interactions. This article describes a process to capture these nursing interventions. METHODS: Nurses at 6 US inpatient SCI centers used 2 in-person meetings and weekly telephone calls over 9 months to develop a taxonomy of nursing patient education efforts and care management. RESULTS: This was subsequently incorporated into a point-of-care documentation system and used to capture details of nursing care for 1,500 SCI rehabilitation patients enrolled in the SCIRehab study. The taxonomy consists of 10 education and 3 care management categories. The point-of-care system includes time spent on each category along with an indication of whether the patient and/or family received the education/care management. In addition, a subjective measure of patient participation in nursing activities is included. CONCLUSIONS: Creation of a SCI rehabilitation nursing taxonomy is feasible, and its use has had an impact on nursing practice. It also has implications for future clinical documentation, because greater accuracy and details of patient education and care management will be a permanent practice in the participating systems at the conclusion of the study.