PubMed · 10272021
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K L Hackett. 1985. Administration structure for the uniform billing process.. https://pubmed.ncbi.nlm.nih.gov/10272021/
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The use of preprinted charting forms saves nursing time and, at the same time, increases completeness and accuracy of documentation. Data for Quality Management (QM) are easily gathered from preprinted charting forms, making the forms an effective tool for building a nursing QM program. The enthusiastic response to the presentation of this program at the American College Health Association's 1998 Annual Meeting in San Diego prompted the authors to share this information with journal readers.
The article reports a study whose purpose was to develop and test the Patient Record Pain Management Assessment Tool, an instrument to evaluate compliance with the American Pain Society's quality assurance standards on acute pain and cancer pain in chart documentation. Content validity, overall validity, and interrater reliability were all found to be acceptable. The instrument is therefore a useful tool for documenting the level of pain management practice in institutional settings.