A closer look at nursing documentation on paper forms: preparation for computerizing a nursing documentation system.
A small scale documentation analysis was conducted to explore the medical and surgical nursing content of the patient record at a large teaching hospital affiliated with Partners Healthcare System (PHS), in preparation for a computerized documentation system. Through this study, we identified a number of problems associated with the paper record that require resolution in the new computerized system, including elimination of documentation redundancy, areas where more structure is needed to properly capture data on nursing practice, and various design considerations to support a more complete and accurate documentation of nursing care.
Kim
Hyeoneui
H
Division of Biomedical Informatics, Department of Medicine, University of California, San Diego, 9500 Gilman Drive #0671, La Jolla, CA 92093-0671, USA. hyeoneui@ucsd.edu
Dykes
Patricia C
PC
Thomas
Debra
D
Winfield
Linda A
LA
Rocha
Roberto A
RA
D005568:Forms and Records Control / Q000379:methods*; D016347:Medical Records Systems, Computerized; D009732:Nursing Care / Q000379:methods*