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Keywords

Clinical informatics, Nursing Documentation, Standardization

 

Authors

  1. COWDEN, SHANNON RN, MN
  2. JOHNSON, L. CLARK PHD

Abstract

Forms capturing redundant data can lead to duplicate documentation. This can be a source of patient and staff frustration, as well as data errors. The definition of a process aimed at examining the data captured on forms documenting similar aspects of patient care is necessary to avoid this problem of duplicate documentation. A data-driven systematic process for consolidation of the multiple redundant forms used in various patient care areas across a healthcare delivery system is proposed and tested using the 21 intake forms currently used by a regional Health Maintenance Organization (HMO). The analytic and subsequent reporting processes used in this project provide a systematic method of forms consolidation that can be applied to other settings.