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PubMed · 8108080

Using system integration to revise documentation.

K O'Brien·G L Landstrom
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Abstract

Within a 10-month time period, a new system-wide documentation common to five hospitals in the Evangelical Health System was designed and implemented. The documentation system is comprised of the Nursing Admission Assessment, Patient Care Plan, Patient Care Flowsheet, and Patient/Family Education Record. Examples of barriers and success factors as well as the system's framework are presented.

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DocumentationForms and Records ControlHospitals, ReligiousIllinoisNursing RecordsJournal Article

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K O'Brien, G L Landstrom. 1994. Using system integration to revise documentation.. https://pubmed.ncbi.nlm.nih.gov/8108080/

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Do preformatted charts improve doctors' documentation in a rural hospital emergency department? A prospective trial.

AIM: To determine if the introduction of preformatted patient record charts improved documentation by doctors in a rural emergency department. METHODS: All medical records of patients who were discharged from the emergency department were collected and analysed for a period of two weeks (control). The preformatted patient charts were then introduced for a further two weeks, and analysed for the presence or absence of key content items RESULTS: After exclusions, 137 control charts and 96 preformatted charts were collected and analysed. It was found that, overall, there was a significant improvement in the number of the key items documented (p<0.005). There was a trend towards improvement in four parameters, but for three other key content items, there was a nonsignificant decline in documentation standards. CONCLUSION: A structured proforma does improve documentation. However, the improvement is small and further studies are required before use of preformatted patient records for the undifferentiated emergency department patients can be recommended.

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