Documentation of care outcomes in an academic nursing clinic: an assessment.
OBJECTIVE
To assess documentation of client data collected at an academic nursing clinic using the Wilson and Cleary Health Related Quality of Life (HRQOL) conceptual model as a framework.


METHODS
A chart audit of 100 randomly selected active client records was conducted.


CONCLUSIONS
Although several significant HRQOL variables were documented, data regarding general health perception and quality of life were not present. The HRQOL conceptual model provided an appropriate structure for evaluating the documentation. Further effort must be made to include key HRQOL dimensions in the clinic's documentation system.


CONCLUSIONS
Documenting the quality of care provided in nursing clinics is essential in order for other professionals and the public to recognize nursing professionals as accountable and credible. This project formed the basis for a computerized outcomes-based client record system.
Davis
A L
AL
Arizona State University, USA.
Holman
E J
EJ
Sousa
K H
KH
D000046:Academic Medical Centers / Q000592:standards*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003151:Community Health Centers; D004506:Education, Nursing; D005260:Female; D006304:Health Status; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009731:Nursing Audit; D009732:Nursing Care / Q000592:standards*; D011361:Professional Competence; D011639:Public Opinion; D011788:Quality of Life; D016896:Treatment Outcome