Nursing documentation: a format not a form.
Nurses have a difficult time committing themselves to the documentation of patient care. Various forms, assessment sheets, and checklists have been created only to prove ineffectual or to be discarded. Our format allows for the documentation of health status and permits nurses to document in the style with which they are most comfortable. The format is designed to elicit critical information and to reflect the hospital's established nursing practice standards. Subjective and objective evaluations conducted over a three month period demonstrated an appreciation for the format, a marked increase in nursing documentation, and a strong commitment by the nursing staff to reflect nursing practice in nursing documentation. A format not a form-is a method that has proven successful.
D001900:Boston; D004282:Documentation / Q000592:standards*; D005069:Evaluation Studies as Topic; D006304:Health Status; D006801:Humans; D008603:Mental Health; D009730:Nursing Assessment; D009736:Nursing Process; D009737:Nursing Records; D010808:Physical Examination