Interdisciplinary documentation in the NICU

Article Abstract:

Streamlining nursing documentation can ease the pressure on health care providers by distributing the workload while protecting the quality of patient care. A streamlining project deals with a document duplication problem in a neonatal intensive care unit wherein each specialty discipline had its own forms and procedures, contributing to the difficulty and lack of organization of information retrieval. The care provider also had a hard time obtaining a clear picture of the patient's status. An interdisciplinary flowsheet, an entry in the Kardex file, a care plan and a teaching record were now the only forms.

Nursing, Nursing care plans

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Forming an integrated documentation system

Article Abstract:

A hospital's steering committee developed criteria for patient and procedure documentation which simplified record-keeping. A database was developed to list relevant information, including admission history and developmental assessment. The new system unified all medical disciplines' care plans, flow sheets, and personal data into a single document. Implementation encountered several staff obstacles which were largely overcome with training and feedback.

Innovations, Hospital records

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Chart reviews made simple

Article Abstract:

Reviewing medical charts can become a simple, efficient process when using a chart review tool that provides a consistent method for gathering data on a patient population. Objectivity, awareness of role responsibilities, and simplicity are the most important criteria for developing a chart review tool. The best chart review tool will permit orderly movement through patient records to develop an accurate care map.

Methods

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