The Documentation Dilemma: A Practical Solution

The well-known problems associated with inadequate nursing documentation have been magnified by current economics. A pilot of a new documentation system in a major teaching hospital revealed the following results: (1) significant reduction in cost of nursing time spent charting, (2) improved documentation of the use of supplies and equipment, (3) improved quality assurance scores, (4) improved nurse and physician satisfaction with nursing documentation, and (5) creation of a model approach to charting for a 1200-member division of nursing.