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Related Experiment Videos

Computerized documentation of case management. From diagnosis to outcomes

S W Utz1

  • 1University of Virginia, School of Nursing, Charlottesville 22903-3395, USA. swu2q@virginia.edu

Nursing Case Management : Managing the Process of Patient Care
|February 6, 1999
PubMed
Summary

Effective patient care documentation is crucial for case managers. This review explores documentation approaches, standardized language, and computerized systems to demonstrate nursing value and support reimbursement.

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Area of Science:

  • Nursing
  • Healthcare Management
  • Health Informatics

Background:

  • Patient care documentation and report writing are core responsibilities for case managers.
  • Evolving healthcare demands necessitate updated documentation strategies.
  • Accurate documentation is vital for tracking patient outcomes and justifying nursing services.

Purpose of the Study:

  • To examine contemporary nursing documentation approaches.
  • To identify new documentation applications within the case manager role.
  • To discuss the significance of documentation for demonstrating nursing practice and securing reimbursement.

Main Methods:

  • Literature review of recent documentation trends in nursing.
  • Exploration of standardized language and multidisciplinary documentation.

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  • Presentation of methods for evaluating computerized documentation systems.

    • Main Results:

    • Analysis of various documentation approaches used by nurses.
    • Discussion of challenges and opportunities in case management documentation.
    • Highlighting the role of documentation in outcome comparison and reimbursement.

    Conclusions:

    • Standardized and multidisciplinary documentation enhance care clarity.
    • Computerized systems offer potential for improved efficiency and data analysis.
    • Robust documentation is essential for validating nursing contributions and financial reimbursement.