Keywords

continuum of care, documentation, interdisciplinary, quality improvement, systemwide change

Authors

1. Brunt, Barbara A. MA, RN, C
2. Gifford, Louise MSN, RN, C
3. Hart, Dee RN, CEN
4. McQueen-Gross, Sharon BSN, RN
5. Siddall, Diane RN
6. Smith, Robert RN, BFA
7. Weakland, Rosalie MSN, RN, CHPQ

Abstract

An increased emphasis on integrated care delivery and the need to access information across the care continuum led to an assessment and modification of the current documentation system at Summa Health System in Akron, Ohio. The goal was to achieve more complete and concise interdisciplinary charting. This article describes the process the two-hospital system developed to achieve integrated documentation reflecting the patient's progress toward team-defined outcomes. Steps in the evaluation and modification of the old system, lessons learned, and results/implications for quality improvement are shared.