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Related Experiment Videos

"Patient focused charting".

L Sinha, M Driedger, J Dick

    Canadian Journal of Nursing Administration
    |June 1, 1988
    PubMed
    Summary
    This summary is machine-generated.

    This study improved nursing charting by integrating care plans and nurse

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    Area of Science:

    • Nursing Informatics
    • Healthcare Documentation Systems

    Background:

    • Traditional narrative charting presents challenges in nursing documentation.
    • A need existed for a structured, user-friendly system to improve patient care recording.

    Purpose of the Study:

    • To develop and evaluate a practical documentation system integrating care plans and nurse's notes.
    • To enhance the quality and efficiency of nursing documentation.

    Main Methods:

    • Implemented a new charting system on a surgical unit.
    • Evaluated the system using chart audits, opinionnaires, and time surveys over 12 months.

    Main Results:

    • Significant increase in chart audit scores (9.05 to 12.75).
    • Significant improvement in charting opinionnaire scores (47.59 to 55.62).
  • Reduction in charting time per patient (22.73 to 18.27 minutes).

    • Conclusions:

    • Integration of care plans and nurse's notes is feasible.
    • The new system improved charting quality and efficiency.