Clinical Nursing Records Study (Executive Summary)

Abstract

Study assigned as part of the FY 84 AMEDD Study Program; examined inpatient nursing documentation issues, testing new documentation forms and concepts. The study purposes were twofold: assess AMEDD nursing documentation system to identify specific problem areas; develop forms and guidelines to address the problems. The study was conducted in four separate phases: (1) In- depth assessment of current AMEDD nursing documentation system used in fixed facilities; (2-4) development, implementation and assessment of tested elements. The investigators were also charged with recommending permanent regulatory changes for inpatient nursing documentation. The study phases were conducted over a three year period; working groups of Registered Nurses and advisors in various capacities were involved during Phase 2, developing tested elements based upon the needs assessment conducted in Phase 1. Proposed changes were field tested at four AMEDD facilities within CONUS.

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Document Details

Document Type
Technical Report
Publication Date
Aug 01, 1991
Accession Number
ADA242334

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  • Martha R. Bell
  • Patricia Twist
  • Terry R. Misener

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