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PubMed · 6914380

Nursing documentation: a format not a form.

J E Barbiasz·V Hunt·A Lowenstein
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Abstract

Nurses have a difficult time committing themselves to the documentation of patient care. Various forms, assessment sheets, and checklists have been created only to prove ineffectual or to be discarded. Our format allows for the documentation of health status and permits nurses to document in the style with which they are most comfortable. The format is designed to elicit critical information and to reflect the hospital's established nursing practice standards. Subjective and objective evaluations conducted over a three month period demonstrated an appreciation for the format, a marked increase in nursing documentation, and a strong commitment by the nursing staff to reflect nursing practice in nursing documentation. A format not a form-is a method that has proven successful.

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BostonDocumentationEvaluation Studies as TopicHealth StatusHumansMental HealthNursing AssessmentNursing ProcessNursing RecordsPhysical ExaminationJournal Article

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J E Barbiasz, V Hunt, A Lowenstein. 1981. Nursing documentation: a format not a form.. https://pubmed.ncbi.nlm.nih.gov/6914380/

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Human metapneumovirus in children tested at a tertiary-care hospital.

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