[A new documentation system to simplify a patient-centered nursing process in ambulatory care and in long-term care in a nursing facility].
In 1995/96, the new care insurance was introduced in Germany, regulating longterm nursing care in the community and in nursing homes. In order to implement the new legislative regulations the Federal Ministry of Labour and Social Affairs commissioned the AKI Institute to develop adequate patient centered quality standards for care planning and documentation. On the results of a multimethod survey a new documentation system was developed that enables a new patient centred approach, putting the client's habits and his or her view of health problems in the centre of nursing action. Traditional formats were altered to facilitate the documentation of the nursing process. The results show clearly that care is now more orientated towards a patient's autonomy and wishes. On the whole, the documentation is clearer and more systematic.
Höhmann
U
U
Agnes Karll Institut für Pflegeforschung (AKI), Eschborn.
Weinrich
H
H
Gätschenberger
G
G
D000553:Ambulatory Care; D004282:Documentation; D005568:Forms and Records Control; D006801:Humans; D008134:Long-Term Care; D009736:Nursing Process; D009737:Nursing Records / Q000592:standards*; D018802:Patient-Centered Care / Q000458:organization & administration*
Neues Dokumentationssystem zur vereinfachten patientenbezogenen Umsetzung des Pflegeprozesses in ambulanter und stationärer Langzeitpflege. Kurzbericht zu einem Forschungsprojekt.