Decreasing documentation time using a patient self-assessment tool.

Abstract

A 1986 audit of 150 randomly selected radiation therapy patient records revealed 147 records containing completed nursing assessment and weekly progress notes. Documentation of care provided was comprehensive, but concern was expressed over the length of time it required--an average of 40 minutes for the patient interview and an additional 20 minutes for documentation. Two strategies were proposed to reduce the amount of time spent in documentation without jeopardizing the detail of information contained in the initial nursing assessment: to pilot a patient self-assessment tool based on our original functional health pattern nursing assessment and to develop a standard flow sheet that contained both frequently used nursing diagnoses and potential interventions. Selected patients completed self-assessment records and discussed them with their primary nurses on the first day of treatment. Based on the pilot data, the forms were modified and revised. In 1987, 50 revised patient self-assessment records were reviewed revealing that both subjective and objective information had improved. Documentation time was reduced and information was more comprehensive.