The nursing plan: innovative home health documentation

Area of Science:

• Healthcare Management
• Nursing Informatics
• Clinical Documentation

Background:

• Current nursing care plan systems often require improvement for efficiency.
• Effective documentation is crucial in home health agency settings.

Purpose of the Study:

• To enhance documentation practices within a home health agency.
• To revise and improve the existing nursing care plan system.

Main Methods:

• A task force was formed to analyze and revise the nursing care plan system.
• Nurses across a five-county service area participated in the system's development.
• The revised system integrates nursing interventions, patient outcomes, and physician plans.

Main Results:

• A totally computerized treatment plan generation system was developed.
• The new system aims to streamline and improve the documentation process.

Conclusions:

• The collaborative development involving nurses led to a comprehensive, computerized treatment plan.
• The revised system is expected to improve overall documentation quality and efficiency in home health care.