The patient problem/nursing diagnosis form: a computer-generated chart document.

Abstract

The INFORMM (Information Network for Online Retrieval & Medical Management) patient problem/nursing diagnosis form is a computer-generated, patient record document of information related to identified patient conditions and patient outcomes. These patient and nursing data, accessible online as well as in paper copy, enhance continuity of care by providing, to all authorized clinicians, a list and history of identified patient problems/nursing diagnoses and the patient's status in terms of the achievement of projected patient outcomes. This cumulative, patient-centered documentation facilitates patient care effectiveness and provides mechanisms to capture and retrieve patient and outcome data for quality improvement and research purposes.