Well-executed model of documentation?

[deborahCNS]

:typing I have been charged with remodeling documentation prior to our initiation of the new electronic medical record (EMR.) My current goal is to examine working models of well-executed documentation. If your organization has a very good to excellent documentation system in place please contact me. I have no pre-conceived ideas as to a model as I think all have strong attributes. I am more interested in implementation. To meet my goals the model would need to drive patient outcome, support nurses in planning care and demonstrate multidisciplinary collaboration. Please contact me if you have any good leads for me. (Yes, I have been called PollyAnna.)

[hayati]

Hi Deborah,

Sorry I'm not writing to help you. I wish I could. I'm interested in what YOU find out! I've been away from the bedside for quite a while (in different countries) and I'm interested in finding out what type of documentation style nurses find most useful/effective in the clinical setting. I.E. charting by exception, checklists, narrative, etc. The clinical documentation that I've been auditing has been minimal and I'd like to know what the other nurses have to say. Again, sorry I can't help. If I get any ideas from my information I will send it to you!

[UM Review RN, ASN, RN]

Our system has recently gone to computerized charting in the ER. I've found that there isn't enough space for narrative notes; I find the patient's history so spread out over a few different fields that I cannot begin to figure out exactly whose history it is. Maybe it's family history. Maybe it's symptoms. Maybe something else, who knows.

So here comes that patient at 0400, snowed with morphine and unable to answer questions--and essentially, I have no real information to work with.

I tell you this so that your system will hopefully improve on this problem.