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An interdisciplinary documentation performance improvement project.

Nancy Davidson1, Kim Egbert, Mary Merchant

  • 1Nephrology/Renal Transplant Unit, Medical University of South Carolina, Charleston, South Carolina 29425, USA.

Journal for Nurses in Staff Development : JNSD : Official Journal of the National Nursing Staff Development Organization
|February 3, 2005
PubMed
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A task force standardized documentation at an academic medical center to improve interdisciplinary patient care planning. This initiative enhanced care coordination across all inpatient populations.

Area of Science:

  • Healthcare Administration
  • Clinical Documentation Improvement
  • Patient Care Coordination

Background:

  • Existing documentation systems lacked standardization at an academic medical center.
  • A need was identified for improved interdisciplinary care planning documentation.

Purpose of the Study:

  • To revise and implement a standardized, interdisciplinary documentation system.
  • To enhance the documentation of care planning for all inpatient populations.

Main Methods:

  • Formation of an Interdisciplinary Documentation Performance Improvement Task Force.
  • Evaluation and revision of the existing documentation system.
  • Implementation of the newly standardized system.

Main Results:

Related Experiment Videos

  • A standardized documentation system was established.
  • The system reflected interdisciplinary planning of care.
  • Implementation processes and outcomes were documented.

Conclusions:

  • The revised documentation system successfully integrated interdisciplinary care planning.
  • Recommendations for future initiatives were proposed.
  • The project demonstrated a successful approach to improving clinical documentation.