"Patient focused charting".

Abstract

A study of charting in the Nursing Division at St. Boniface General Hospital identified problems with the narrative style of charting. This project was designed to develop and evaluate a practical, easy to use documentation system, with a structure for recording care as decisions were made. Integration of the care plan and nurse's notes was achieved, making documentation individualized to the patient and reflective of nursing practice. The charting system was tested on a 30-bed surgical unit with 25 nursing staff and evaluated through a chart audit, charting opinionnaire and time survey. Four evaluations were done, one prior to change and at 3, 8 and 12 months after implementation. Chart audit scores increased significantly from a mean of 9.05 to 12.75. Mean scores on the charting opinionnaire increased significantly from 47.59 to 55.62. Mean time spent charting per patient in 24 hours decreased from 22.73 to 18.27 minutes. These results indicate that integration of the careplan and nurse's notes is possible with improvement in charting quality.