The purposes of this study were
1) to assess the currunt documentation system
2) to identify the problems in communication regarding to documentation
3) to develop new documentation system
4) to suggest effective communication channel using new documentation system
Research was conducted by direct observation, chart review, staffs interview and servery.
Results were as follows :
1) nursing care plans were not used in ongoing care
2) documentation format was primarily narrative and charting was time consuming
3) documentation did not reflect the nursing process
4) patient records were not used as effective communication tool between case manager and part time nurse
5) difficult access to patient record for nurse manager created inefficiency in coordinating
6) documentation of patient education did not describe the precise contents of education, and the responses of the patients and evaluation
To solve these problems, new documentation format was developed. With new formats nurses :
1) use standardized care plan which contains nursing diagnosis, expected outcome, time frame for evaluation, flow sheet for updating the plans
2) leave one copy of care plan at patient home for mutual agreement with patent and communication among nursing staffs
3) carry one copy of care plan for updating
4) document and evaluate the patient education using education check list keeping in patient´s home
5) document nursing process in focus charting visit report
6) carry one copy of visit report
7) have one copy of visit report which was deligated to part time nurses
8) use documentation in direct communication with part time nurse
9) use beeper and memo to promote communication
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