Gryfinski J J, Lampe S S
Clin Nurse Spec. 1990 Winter;4(4):200-5.
Documentation is an issue of importance to nursing for many reasons. Quality patient care depends upon complete and accurate information among care givers, third party reimbursement is based on documented care, inefficient documentation systems and behaviors are costly to an institution in terms of salaries, overtime pay and dissatisfied nurses, and documentation is an essential component of institutional licensure and accreditation. The authors describe documentation issues that prompted Christ Hospital of Oak Lawn, Illinois to revise their documentation system, selection of Focus Charting, the educational process for a nursing staff of 1200, and a critique of the educational process. Clinical nurse specialists played a key role in each step of the project.
由于多种原因，记录对护理工作至关重要。优质的患者护理依赖于护理人员之间完整准确的信息，第三方报销基于记录的护理情况，低效的记录系统和行为在薪资、加班费以及护士不满方面会给机构带来高昂成本，并且记录是机构执照颁发和认证的重要组成部分。作者描述了促使伊利诺伊州橡树草坪基督医院修订其记录系统的记录问题、聚焦记录法的选择、针对1200名护理人员的教育过程以及对该教育过程的批判。临床护理专家在项目的每一步都发挥了关键作用。
