Accession Number:

ADA242774

Title:

Clinical Nursing Records Study

Descriptive Note:

Final rept. Jan 1984-Oct 1987

Corporate Author:

ARMY HEALTH CARE STUDIES AND CLINICAL INVESTIGATION ACTIVITY FORT SAM HOUSTON TX

Report Date:

1991-08-01

Pagination or Media Count:

1126.0

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.

Subject Categories:

  • Medicine and Medical Research

Distribution Statement:

APPROVED FOR PUBLIC RELEASE