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Developing a documentation system that works.

J Manion

    Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN
    |March 1, 1986
    PubMed
    Summary
    This summary is machine-generated.

    Developing an effective obstetric and neonatal nursing documentation system requires a structured approach. This guide outlines key steps from assessment to evaluation for accurate patient record-keeping.

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    Area of Science:

    • Nursing Informatics
    • Healthcare Documentation Systems
    • Obstetric and Neonatal Care

    Background:

    • Accurate and complete documentation is crucial for obstetric/neonatal nursing services.
    • Developing individualized documentation systems presents significant challenges.
    • Standardized approaches are needed to streamline system creation.

    Purpose of the Study:

    • To describe a systematic process for developing individualized obstetric/neonatal nursing documentation systems.
    • To provide a practical framework for nursing services to improve patient record-keeping.
    • To facilitate the creation of efficient and effective documentation tools.

    Main Methods:

    • The study outlines a phased approach to system development.
    • Key phases include assessment, planning, implementation, and evaluation.

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  • Emphasis is placed on tailoring the system to specific service needs.

    • Main Results:

    • A structured, step-by-step methodology simplifies the development process.
    • The described approach ensures comprehensive coverage of essential documentation elements.
    • Implementation of the outlined steps leads to improved recording accuracy and completeness.

    Conclusions:

    • Developing a tailored documentation system is achievable through a systematic process.
    • The described methodology supports the creation of efficient and accurate obstetric/neonatal nursing records.
    • Continuous evaluation ensures the system remains effective and meets evolving needs.