Documentation and the Nurse Care Planning Process

Excerpt

The evidence reviewed in this chapter suggests that formal recordkeeping practices (documentation into the medical record) are failing to fulfill their primary purpose, of supporting information flow that ensures the continuity, quality and safety of care. Moreover, disproportionate attention to secondary purposes (e.g., accreditation and legal standards) has produced a medical record that is document centered rather than patient focused. Cumbersome and variable formats, useless content, poor accessibility, and shadow records are all evidence of the extraordinary failure of the medical record. Given the exorbitant cost of the record and urgent need for tools that facilitate the flow of patient-centric information within and across systems, it is imperative to develop broad-based solutions.