Clinical Nursing Records Study
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: In-depth assessment of current AMEDD nursing documentation system used in fixed facilities; development, implementation and assessment of tested elements. The investigators were also charged with recommending permanent regulatory changes for inpatient nursing documentation. Findings: Phase 1: Perceived problem areas of documentation included issues related to directions for clinical record use and specific DA nursing forms; the necessity of transcribing orders from one paper to another; the lack of a standardized discharge format; the lack of standardized specialty area flowsheets; the overall redundancy and fragmentation of patient progress in the medical record. Phase 2: Priorities set by working and advisory groups were directed toward revising rather than completely overhauling the current system.
Document Details
- Document Type
- Technical Report
- Publication Date
- Aug 01, 1991
- Accession Number
- ADA242774
Entities
People
- Martha R. Bell
- Patricia Twist
- Terry R. Misener