Nursing documentation has a central role in the quality of care and revenue issues facing the modern acute care hospital. In addition to excellent clinical care, today's nurses must also meet a complex array of regulatory and institutional management challenges. It is imperative that they be given efficient systems and tools to provide excellent documentation without compromising care.
Beyond the obvious patient care issues, an inefficient or inaccurate nursing documentation system can have significant impact on quality, costs and revenue at your institution. Redundant information requirements waste valuable time for nurses and physicians. Missing or incomplete documentation canlead to frustration for care providers and unbilled or denied charges. Multiple versions of charts and forms for different patient units lead to confusion, inconsistencies and ineffective communication among the professional staff. Poor documentation of complications or severity leads to significant lost revenue. The list of problems associated with nursing documentation can go on and on. Health Systems Management Network can provide an objective look at your current documentation system, recommend changes and aid in the implementation of a new system.
Highly experienced nursing and nursing management specialists with Health Systems Management Network will work closely with your staff to establishan overview of the current nursing documentation system. This review will establish current strengths and weaknesses in:
This assessment is accomplished by an "audit" of a significant number of current and past cases to determine such aspects as completeness, conciseness, accuracy, efficiency, legibility and ease of use. Equally important as the document reviews are tours of selected units and interviews and observationsof staff and management.
Health Systems Management Network will take the lead in designing a new nursing documentation system that works within the realities of your institution. Our focus will be to retain the best elements of the current system and revise or introduce new solutions in problem areas. Our recommendations go far beyond the revision of forms or software. Our systemic solutions address staff and management attitudes, educational needs and interdisciplinary feedback. In general, we strive to standardize and decrease documentation requirements and paperwork. We place particular importance on the design of systems that facilitate communication and support documentation requirements- not in the imposition of new or additional requirements.
In our experience, we have found that the communication of the importance of documentation, and the value placed upon documentation by management,is fundamental to the success of a new system. By designing a well-planned implementation of a new system that includes staff education and motivation, Health Systems Management Network can help change the culture of your hospital from one that views documentation as a chore, to one that understands and accepts the value of excellent documentation
