"Patient focused charting". 1988

L Sinha, and M Driedger, and J Dick

A study of charting in the Nursing Division at St. Boniface General Hospital identified problems with the narrative style of charting. This project was designed to develop and evaluate a practical, easy to use documentation system, with a structure for recording care as decisions were made. Integration of the care plan and nurse's notes was achieved, making documentation individualized to the patient and reflective of nursing practice. The charting system was tested on a 30-bed surgical unit with 25 nursing staff and evaluated through a chart audit, charting opinionnaire and time survey. Four evaluations were done, one prior to change and at 3, 8 and 12 months after implementation. Chart audit scores increased significantly from a mean of 9.05 to 12.75. Mean scores on the charting opinionnaire increased significantly from 47.59 to 55.62. Mean time spent charting per patient in 24 hours decreased from 22.73 to 18.27 minutes. These results indicate that integration of the careplan and nurse's notes is possible with improvement in charting quality.

UI MeSH Term Description Entries
D009731 Nursing Audit A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. Audit, Nursing,Audits, Nursing,Nursing Audits
D009737 Nursing Records Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress. Records, Nursing,Nursing Record,Record, Nursing
D010347 Patient Care Planning Usually a written medical and nursing care program designed for a particular patient. Nursing Care Plans,Goals of Care,Plans, Nursing Care,Care Goal,Care Goals,Care Plan, Nursing,Care Planning, Patient,Care Plans, Nursing,Nursing Care Plan,Plan, Nursing Care,Planning, Patient Care
D006694 Holistic Health Health as viewed from the perspective that humans function as complete, integrated units rather than as aggregates of separate parts. Holistic Medicine,Holistic Therapies,Medicine, Holistic,Whole Person Health,Wholistic Health,Medicine, Wholistic,Wholistic Health Care,Wholistic Medicine,Wholistic Therapies,Care, Wholistic Health,Health Care, Wholistic,Health, Holistic,Health, Whole Person,Health, Wholistic,Holistic Therapy,Person Health, Whole,Therapies, Holistic,Therapies, Wholistic,Therapy, Holistic,Therapy, Wholistic,Wholistic Therapy
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man

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