Patient-Centered Documentation

Abstract

After 2 years of experience with a basic computerized system for documenting care, the nursing leaders in an inner city hospital undertook a redesign process to create an effective and efficient system for documentation that also provided data for monitoring care processes, patient outcomes, and staff performance. The basic system was a source of frustration and dissatisfaction for nurses, physicians, and managers. The redesigned system has exceeded the expectations of staff and physicians and delighted managers. Managers can now access the clinical data collected by the staff to create meaningful reports describing the patient population, identifying patients needs, monitoring staff compliance with care standards, and tracking improvements in care processes.

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