Improving clinical documentation quality.
A multidisciplinary documentation quality team was appointed four years ago with the charter to revise the admission nursing assessment form, eliminate the traditional handwritten nursing care plan, establish a method to utilize standards of care and standards of practice as the basis for individualizing the patient plan of care, establish flexible charting systems for specialty sections, and develop clear and concise guidelines to accompany specialty area documentation systems. This article provides an overview of the project and the outcomes realized through commitment, collaboration, and cooperation.
Quigley
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James A. Haley Veterans Affairs Medical Center, Tampa, FL.
Mathis
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Nodhturft
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D003625:Data Collection / Q000592:standards; D004282:Documentation / Q000592:standards; D005568:Forms and Records Control; D006801:Humans; D007591:Joint Commission on Accreditation of Healthcare Organizations; D008332:Management Quality Circles / Q000458:organization & administration*; D016347:Medical Records Systems, Computerized; D009737:Nursing Records / Q000592:standards*; D009937:Organizational Objectives; D017063:Outcome Assessment, Health Care / Q000592:standards*; D010343:Patient Admission; D010347:Patient Care Planning / Q000592:standards*; D010348:Patient Care Team / Q000592:standards; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States