Development and use of preprinted forms and adhesive labels in medical record charting.
Clear delineation of specific clinical and administrative responsibilities (eg, content requirements, cost constraints) is necessary in the development, approval, and implementation of effective preprinted documentation materials. Input early in the development stage from medical record and legal department staff ensures that proposed materials will meet organizational and legal standards. The development and use of time-saving preprinted documentation materials in medical record charting by the Johns Hopkins Oncology Nutrition Service is described. We conclude that the use of preprinted materials expedites and enhances both the consistency and quality of documentation.
Fatzinger
P
P
Oncology Nutrition Service, Johns Hopkins Hospital, Baltimore, MD 21205.
Kammer
A
A
Garrett
M
M
D004045:Dietary Services; D004282:Documentation; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards; D009747:Nutritional Physiological Phenomena