Quality assurance as reflected in documentation.

Abstract

Georgetown University Hospital's Gastroenterology Log Book was initially designed to assist the staff in streamlining record keeping. While the log book has not replaced the patient's chart, it has evolved into a major source of patient information and documentation. Documentation from the log can be utilized as a method to assure standardized nursing and physician delivery of care. Patient/procedure assessment is recorded in three stages: 1) preprocedure; 2) intraprocedure; and 3) postprocedure. The method of recording information is clearly delineated in the log book. The log book follows recommended American Society for Gastrointestinal Endoscopy guidelines. The book serves as a method of compiling data and facilitating nursing and medical intervention without duplicating services. With methodically collected data, the information can easily be transferred to data base systems at a later date.