The development of a patient history and data base form

Providing adequate information within a concise documentation format remains a problem in healthcare institutions throughout the United States. A task force was developed at Memorial Sloan-Kettering Cancer Center in New York, NY, to revise the documentation system, including the comprehensive adult patient history and data base (PHDB) form. The new PHDB form consists of a patient or family self-report section and a nursing assessment section. A pilot project using the form was implemented and evaluated. The form was found to be useful and efficient and was recommended for hospital implementation. This article describes the development of this new form and its ongoing monitoring and evaluation.