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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 49Documentation and the Nurse Care Planning Process

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Tools are needed to support the continuous and efficient shared understanding of a patient’s care history that simultaneously aids sound intra- and interdisciplinary communication and decisionmaking about the patient’s future care. Such tools are vital to ensure that the continuity, safety, and quality of care endure across the multiple handovers made by the many clinicians involved in a patient’s care. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. Since recordkeeping systems serve multiple purposes (e.g., legal requirements, accreditation, accountability, financial billing, and others), a tension has arisen and is undermining the primary purpose of the record and instead fueling discontinuity of care, near-misses, and errors. Among the more specialized types of documentation is the plan of care, a requirement of the Joint Commission.1, 2 Though planning and plans should facilitate information flow across clinician providers there is little generalizable evidence about their effectiveness.

In the first part of this chapter, evidence from studies on nursing documentation, care plans, and interdisciplinary plans of care is presented and synthesized into a framework for the Hands-on Automated Nursing Data System (HANDS) method. The method is an intervention that addresses the need for broad-based standardization of key aspects of documentation and communication to facilitate patient-centric information flow. HANDS standardizes the plan of care documentation and processes by replacing the current widely variable forms. It supports interdisciplinary decisionmaking that is based on the shared knowledge from clinicians. Finally, a case study presenting the history and future plans for the ongoing refinement of the HANDS method is presented.

Research Evidence

Recordkeeping Practices of Nurses and Nursing Documentation

Information work is a critical part of the medical endeavor. Strauss and Corbin3 note that trajectory work, as they view medical care, requires information flow before and after each task or task sequence to maintain continuity of care. Tasks are not isolated but are intertwined and build on one another to achieve patient goals. Nurses bear a large burden in both managing and implementing the interdisciplinary team’s plan for the patient, as well as documenting the care and progress toward goals. As a result, nurses spend considerable amounts of time doing information work. There are several genres of nursing documentation studies: those that examine recordkeeping practices as a whole, those that examine issues relating to the documentation (time, content, completeness), and comparative evaluations of different types of changes in the documentation regime including automation versus paper. Taken together, these provide both detailed and broad knowledge of nurses’ recordkeeping practices and highlight the reasons why any change (manual or computerized) is so difficult to integrate into nursing practice.

General Recordkeeping Practices of Nurses

Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance.4–7 Studies, however, reveal surprisingly little evidence of the linkage between recordkeeping and these outcomes. The literature features multiple exhortations and case studies aimed at improving nurses’ recordkeeping in general8–10 or for specific diagnoses.11, 12

The literature also reveals the tensions surrounding nursing documentation. These include: the amount of time spent documenting;13–15 the number of errors in the records;9,16,17 the need for legal accountability;18–20 the desire to make nursing work visible;21 and the necessity of making nursing notes understandable to the other disciplines.22, 23 For the purposes of this review, we confine ourselves to discussions of either manual or automated nursing systems of documenting patient care, primarily in hospitals. As we have found, while there are good and well-designed individual studies, the different methodologies, populations studied, and variables analyzed have led to little generalizability across the research, making comparisons between them impossible.

There are several literature reviews of nursing documentation systems. Urquhart and Currell24 completed the most systematic and comprehensive review, examining the literature through 2004. They focus on nursing record systems as variations in the systems effect nursing practice and patient outcomes. Currell and Urquhart conclude that nurses experience tensions between patient care needs and hospital management-promoted documentation rules. They also found that the studies show both mixed responses to new systems and inconclusive links between the nursing documentation system used and its impact on patient care. Also noted was the lack of standardization among systems.25

In a more targeted literature review, Langowski26 examined the relationship between quality health care, particularly safety, and point-of-care online nursing documentation systems. Unlike Currell and Urquhart,25 Langowski found that overall documentation quality improved with an online electronic health record (EHR). The measures used, however, varied between the studies, and documentation impact on quality was assessed through evaluating the presence of certain types of information and the frequency of data entry. The accuracy of the information was not evaluated. Nurses’ satisfaction with documentation systems has also been used as a measure of quality though the relationship between satisfaction and documentation is never clearly delineated. The variation in the definition and measures used for evaluating quality is characteristic of this literature.

The final review was carried out by Karkkainen, Bondas, and Eriksson.27 They conducted a metasynthesis of 14 qualitative research reports to determine how well individualized patient care was represented in nursing documentation. Karkkainen and coworkers identified three themes in the literature reflecting the tensions in the record: demands of the organization, nurses’ attitudes and duties, and the patient’s involvement in care. This mirrors the findings of Currell and Urquhart. In conclusion, Karkkainen, Bondas, and Eriksson argue that individualized patient care is not visible in nursing documentation, and that current methods used to standardize communication in the records (forms with check-off lists) contribute to this gap. In another work, Karkkainen and Eriksson28 note that, although standardized forms of documentation can enhance concise and directed information, poorly designed forms may enhance document content but do little to support patient-centric care. The challenge is to design systems that are patient focused but also reap the benefits of standardization in terms of more accurate, precise, and up-to-date information transfer among all members of the interdisciplinary team.

Several single studies provide additional insight into nursing recordkeeping practices. Allen29 examined nurses’ views of the nursing record and its routine usage in practice. Using observations and interviews, Allen found that nurses were ambivalent towards the records, both seeing them as a symbol of the place of nurses in the clinical arena, but also reporting that the records are too heavily structured by management, a finding echoed throughout the literature (e.g. Lee and colleagues30). As a consequence, Allen points to the practice of nurses developing shadow documentation systems (informal nursing records and ward diaries) that help nurses maintain a high-level overview of the patient’s care on one’s shift.

In another qualitative study, Hardey and colleagues31 observed nurses in five acute elderly care wards at a district general hospital in the south of England. They argue that “scraps,” individualized information systems, contained a unique combination of personal and professional knowledge and changed dynamically in response to patient care on a shift. The main source of information in the scraps was information conveyed during the nurse handover. This finding suggests that scraps provide information not found in the patient record. Instead the scraps contain the summarized or synthesized version of the patient’s story that includes only the information the nurse feels is needed to carry out care effectively on one’s shift.

Ngin32 picks up on the idea of information work as discussed by Strauss and Corbin3 and provides an in-depth analysis of nurses’ retrieval, interpretation, documentation, and passing of information. She, too, found that nurses relied less on the formal forms of documentation in the medical record and the care plan than on informal sources; her subjects preferred getting information directly from other nurses who had first-hand, observational knowledge of patients or from summary documentation, such as in Kardexes or personal notes. Ngin quoted nurses as saying, “The Kardex is a ‘living document’ which nurses have dubbed the Bible of nursing care. On the other hand, nurses tend to regard care plans as ‘just a requirement’”32 (p. 81). Ngin also differentiates between coordination of care (which she saw as the role of the Kardex, various worksheets, and more personalized information systems) and continuity of care (which she viewed as sustained by handovers).

In combination, these reviews and studies indicate that nursing documentation in the medical record does not meet the espoused purpose of being a communication tool that supports the continuity, quality, and safety of care. The evidence presented in this section also points to several conditions that perpetuate misunderstanding of nursing work and the means to track it. First, there is wide variation in recordkeeping practices between units and between health care organizations. Second, nurses heavily utilize shadow recordkeeping systems to aid in immediate patient care activities and decisions. Finally, there is an overwhelmingly negative attitude toward formal recordkeeping—either outright hostility or the view that documentation is “just a requirement.”

Representativeness and Completeness of the Content

In several more targeted studies, the central issues of concern were how well the records reflected the care given and accuracy of the patient’s condition. Tornvall and colleagues33 audited EHR records and found that reports of medical status and interventions were more prevalent than nursing status. The authors concluded that nursing documentation was limited and inadequate for evaluating the actual care given. Ehrenberg and Ehnfors’34 triangulation between data from a chart review and interviews of nurses revealed little agreement between the records and the care nurses reported as having given. The researchers went so far as to state in their findings (p. 303) that “there are serious limitations in using the patient records as a data source for care delivery or for quality assessment and evaluation of care.”34

Another set of studies examined the completeness of nursing documentation; these typically utilized chart review and audit as a methodology. The issue of completeness is important; Croke35 cites failure to document as one of the six top reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and Kalfoss36 found many gaps in nursing documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time. Taylor37 found that many of the care plans reviewed did not convey the specific information necessary to carry out the required procedure. One third of the nurses in this study mentioned accessing written documentation but did not express any preference for care plans.37

Other completeness studies have evaluated the impact of the form type and content required. In a controlled clinical trial utilizing a chart review method, Sterling38 analyzed wound assessment documents from three different units. While more of the important details of wound assessment were recorded when using a wound assessment chart, missing information was found for both charting methods (conditions) in the study. In another controlled clinical trial with home care nurses, Tornkvist and colleagues39 administered an educational intervention focusing on pain management. Their findings indicated that several statistically significant improvements in care were achieved after the introduction of the pain-advisers in the study units. Most pertinent to this chapter, the nurses’ satisfaction with their written documentation on pain increased with the addition of several new types of assessments used for charting pain.39

While computerization has been referred to as a cure for incomplete records, the evidence on this is also mixed. Larrabee and colleagues40 found that completeness increases over time after system implementation, with expected gains not being realized until 1 year after implementation. Care planning systems are also not immune from problems with the completeness of documentation. While Bjorvell and colleagues41 reported increased completeness of documentation, particularly in the proportion of discharge planning notes, Griffiths and Hutchings’42 audit of records from home health care nurses found initial nursing assessments poorly documented, affecting later care.

The studies in this section indicate two things. Completeness of a record may have an impact on the quality of care, but only if it reflects completeness of the right content. Echoed again here is that document focus, rather than the patient-centric nature of the medical record, does little to support shared understanding by clinicians of care and the communication needed to ensure the continuity, quality, and safety of care. The typical content and format of documentation—and its lack of accessibility—have also resulted in document-centric rather than patient-centric records.

Time Spent Documenting

Time spent documenting patient care is generally not regarded by nurses as being patient care, even though there is a Nursing Intervention Classification (NIC) term for it. Studies focused on time indicate that nurses spend a significant amount of time recordkeeping. In the most comprehensive literature review on time, Poissant and colleagues14 reviewed 11 studies examining documentation time before and after moving from a manual to an online system. Of these studies, six reported a time savings when using a computer. There was up to a 25 percent savings by nurses charting with bedside systems. Three studies reported increased time, particularly in the one study that employed handheld computers. However, of the three studies that assessed nurses’ efficiency by using the patient as the sampling unit, the results were negative—more time was spent on documentation per patient after system implementation, with increases ranging from 7.7 percent to 128 percent. The authors propose that time efficiencies are gained by standardized forms in systems, although some systems require more information to be documented.14

Other studies have exposed the overall documentation burden carried by nurses. Hardey and colleagues31 found that recordkeeping was given lower status and priority than was direct patient care. It was also viewed as excessively time consuming. Nurses regularly copied data from the medical record and other documents to create personal records that guided their activities. Korst and colleagues13 conducted a work-sampling study over a 14-day period. Out of 2,160 observations, the average percent of time nurses spent on documentation was 15.8 percent; 10.6 percent for entry on paper records and 5.2 percent on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2 percent vs. 12.4 percent, respectively). Time of day is also a factor in retrieving information.

The series of studies in this section indirectly expose the cost implications of maintaining medical records that offer little assistance to clinicians in the provision of patient-centric care. Moreover, maintaining medical records that bring little clinical value not only wastes nurses’ time but also limits the time available to engage in value-added care activities. The cost implications alone justify a call-to-action to redesign documentation systems so that they are patient-centric and aligned with intended purposes.

Studies That Focus on Improving Documentation

Deficiencies in the nursing record, such as problems with accurately representing the patient, the time-consuming nature of recording, and the completeness of the record, have led to a series of interventions aimed at improving nursing documentation. The impetus for changing nursing documentation has come from several sources: hospital management, the nurses themselves, and nursing researchers. Compliance with legal mandates, paperwork reduction campaigns, and meeting professional standards are also common reasons for changing recordkeeping regimes.

The changes made to the documentation process to reach these goals vary broadly. Much of this literature is characterized by contradictory case studies. Scharf43 reported a case study of one hospital that simplified a set of complex forms to enable nurses to spend more time caring for patients while still meeting the Joint Commission’s documentation requirements. Another case study44 involved a change from a preprinted form to a free-text, handwritten care plan for each patient. The studies reviewed include examples of those focused on understanding users’ needs (through assessing attitudes and opinions) and those focused on implementing and evaluating interventions designed to improve documentation.

Dillon and colleagues45 conducted a survey to assess nurses’ readiness to adopt a new EHR. Their findings indicated that nurses had a positive overall attitude, although nurse age was a significant factor in determining nurses' attitudes regarding the EHR. Nurses were concerned, though, about the impact of the new EHR on quality health care delivery. In closing Dillon and coworkers noted that “these results clearly show that the nurses have real concerns about the new impending computer system and that the new system may be risky and might remove the human component of what they do”45 (p. 144). For example, a comment made by one nurse reflected the concerns of many, “I just don't want the system problems to interfere with patient care.” One of her colleagues also commented, “I'm nervous about it [the impending system implementation]—hoping that it will not slow down my productivity—or be too time-consuming”45 (p.144).

Other studies have used educational interventions designed to improve documentation alone or documentation and care. Karkkainen and Eriksson46 completed a pre- and postintervention study, which involved an educational intervention to have nurses apply a theory of caring science to the care plans, to promote a more patient-focused documentation. Chart audit was done pre- and postintervention, and questionnaires assessed nurses’ attitudes about this theory-based recording method. The major change observed was more attention by nurses to patient views and increased recording of these in the plan.46

Studies of computerized charting and care planning systems usually provide some measure for nurses’ satisfaction. Two surveys of nurses’ attitudes toward computerization are important to note. Axford and Carter’s47 study on how nurses believed computer technology impacted their practice is important in this regard. Their survey asked about resource consumption, nursing work practices, and professional and patient outcomes. Their findings indicated that nurses did not think technology would have a negative impact on practice. This was true for both those knowledgeable about computers and those less familiar with them— although the strength of this belief did vary, with experts feeling more strongly.

Other researchers have examined the effects of computers on nursing documentation directly. Nahm and Poston48 did a quasi-experimental, modified time series study that measured the effects of the nursing module of a point-of-care clinical information system on nursing documentation and patient satisfaction. Data were collected before implementation, and after implementation at 6-, 12-, and 18-month intervals. Compliance with items applicable to nursing documentation in the JCAHO Closed Medical Review Tool was used to assess the quality of nursing documentation. Nahm and Poston found a statistically significant increase in the quality of nursing documentation after system implementation and a reduction in the variability of charting. Most importantly, charting compliance increased and continued at the 12- and 18-month time points after initiation of the new system. This indicates that change is incremental, and that longitudinal studies are critical to assess the impact of computer systems.

The body of the literature reviewed in this section provides evidence indicating that well-constructed interventions, such as education and revising formats (automation and forms), can enhance documentation and improve patient care. The evidence also suggests that there is a time-related pattern to user satisfaction, perceptions of value, and achievement of desired documentation outcomes following the implementation of new computer information systems. Nonetheless, the findings must be interpreted with caution due to wide variation of the settings examined, interventions applied, and methods of evaluation. As with all of the literature in this area, the main limitation is lack of generalizability, due primarily to the wide variation of documentation practices within and across organizations.

Nurse Care Planning and Plans

In health care organizations, the EHR, oral reports, handoffs, conferences, and health information technologies (HIT) are intended to facilitate information flow. In particular, the JCAHO specifically conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care.2 The Essentials of Baccalaureate Education for Professional Nursing Practice,49 drafted by the accrediting body the American Association of Colleges of Nursing, lists several core competencies that directly relate to the nurse’s care planning process including the ability to “…diagnose, plan, deliver, and evaluate quality care” (p. 11), “use appropriate technologies in the process of assessing and monitoring patients” (p. 14), “apply health care technologies to maximize optimal outcomes for patients” (p. 16), and “develop a comprehensive plan of care…” (p.16). Although there appears to be clear value to effective care planning and the process of communicating the plan, evidence of this in the literature lacks specificity.

The patient care planning literature encompasses a wide variety of concepts, studies, and interventions. The main subdivisions of patient care planning in the literature are advance care planning (care at the end of life), case management (working with the entire medical team and associated professionals), and critical pathways or protocols for treating specific diseases. As defined, these categories are all potential conceptual matches and should encompass nurse-related care planning and plans. The majority of the care planning literature, however, is disease-oriented or medically focused, with little attention to the actual judgments and actions nurses take in carrying out the interdisciplinary plan at the point of care. Nor does this literature evaluate the impact of nursing care on patient outcomes. We believe the following illustrates the content of literature related to nurse care planning and plans.

Several studies have been done focusing on the introduction of the Scandinavian VIPS (well being, integrity, prevention, safety) model into care planning. Ehrenberg and Enfors34 performed a stratified, randomized controlled trial using chart audit and interviews. They reported that their study group that received a new form and educational intervention exhibited increased completeness and correctness of documented information, although there were still some areas in which the control group documented better than the study group.

Care plan findings from Mason’s50 qualitative study indicated that care plans were not thought to adequately represent the patient, and consequently were not used in the planning or evaluation of care. Observations conducted as part of this study confirmed that the major guides to practice were report, direct observation of the patient, and bedside charts. In these clinical units, the care plan was viewed as actually discouraging thinking, because the standardized formats hindered individualized care by operating as check-off lists that discouraged nurses from engaging in mindful care planning. In one unit, however, the care plans were successfully integrated with practice.50 Nurses’ attitudes toward care plans in this unit were generally positive and the plans were used to aid in explanation and communication, and to guide practice. In this unit, care plans were kept at the bedside. The success of nurses’ adoption of the care plans was attributed to the fact that they were perceived as clinically driven, more representative of the patient’s condition, and there was a sense of local ownership.

Smith and colleagues51 studied the implementation of a computerized care planning and documentation system, using the NIC and nursing outcomes classification (NOC) framework. Data were collected through questionnaires, observations, and chart audits both before and after computer implementation. Post implementation data revealed that the nurses’ attitudes toward computers were more negative and charting time was unchanged; however, chart audits revealed improvement in the completeness of the nursing record.

In research where the intervention has focused on changing the care planning process, findings have shown that patient outcomes can be improved. Implementation of a care pathway for post surgical patients, to streamline nursing care of postoperative colon resection patients, resulted in a statistically significant shorter length of stay.52 In another controlled study, From and colleagues53 found that new care planning forms, as opposed to a narrative written in the medical record, could be associated with earlier recognition of patient problems, a shorter length of stay, and a higher accuracy in planning the discharge time.

Other studies have reported finding previously noted problems in the care planning practices. Research on the effects of the NANDA International, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) terminologies in the care planning process has also shown mixed results. Scherb53 found that nursing care did make a difference in patient outcomes. However, because the method of data capture, it was impossible to identify the nursing diagnoses and interventions that contributed to the positive patient outcomes.54

In a related study, Lillibridge55 found that when nurses were asked to list the type of data they would normally collect using specific examination techniques, 23 percent provided nursing assessment details. It can be argued that if nurses were provided with an explicit nursing framework (and language) to document and communicate about their care that nurses and the interdisciplinary team members would more readily understand the importance and impact of nursing care and patient outcomes. Others have also found that the care plans typically do not reflect actual nursing practice.56, 57

Even when care planning interventions are similar, as in the case of the introduction of the Scandinavian VIPS method for nursing documentation, results vary among studies. Studies by Darmer and colleagues58 show both more methodological rigor and more positive results. This controlled, longitudinal study introduced the VIPS care planning model to nurses on eight units (four study and control units, respectively). The intervention consisted of different educational interventions prior to utilizing the VIPS care planning model. Data included surveys of nurses’ attitudes towards documentation and their knowledge of the new regime. Nurses in the study group had more confidence in their ability to create good care plans and did better than the control group on the knowledge tests. Overall, the nurses in the study by Darmer and coworkers were more positively predisposed towards documentation than those in another VIPS study, by Björvell and colleagues.41

The Björvell and colleagues41 study also featured a VIPS intervention and results overall were positive. There was a statistically significant score increase in quantity (P values for the quantity variables ranged from P < 0.0001 – 0.0003) as well as quality of the nursing documentation (P values of the quality variables ranged from P < 0.0001 – 0.0002). In a followup study, Darmer and colleagues59 reviewed 600 charts utilizing the VIPS model at four sites using a standardized audit tool. They found that nursing documentation significantly improved during the course of the study (P = .00001). After the second year, the participants used the keywords appropriately and correctly according to the VIPS model. Overall, this structured implementation program significantly improved nursing documentation.

Implementing a new care planning system without sufficient cultural, educational, and organizational support has been identified as leading to problems. Educational interventions, in particular, are a major focus in the literature. Hansebo and colleagues60 found that although care planning documentation increased after an educational intervention, the level of assessment was low. The authors concluded that educational interventions were needed to improve clinical judgment.

Lee61 also identified major educational issues associated with the implementation of computerized documentation systems. He argues that launching a care planning system alone, without knowledge of the diagnoses or how to use the care plans in clinical decisionmaking, limits their utility. For Lee and colleagues,30 the new system also increased nursing workload, primarily due to a lack of computers, and competition for terminals with other professionals and students. In the end, the nurses found the care plan lacking in three aspects: (1) content, primarily the inability to individualize patient care; (2) poor system function; and (3) lack of system integration with the other information technology systems. In another article, Lee and Chang62 report on an interview-based evaluation of this system. In this latter study, the nurses interviewed saw the new system as paperwork and not patient-oriented.

The quality of and implementation strategy for care planning systems has impeded adoption as much as the actual care plan within the system. Ammenwerth and colleagues63 found that planning and documentation of tasks (P = .004) and report writing (P = .019) required significantly more time with the computer based system than with the paper based system. For the care planning module, no statistically significant difference between the study and control groups was seen due to the limited number of items. At the conclusion of Ammenwerth and colleagues’ study, seven nurses (58 percent) agreed that the PIK software application saved time for care planning, but only three agreed that PIK saved time for documentation of tasks or for report writing. The majority of nurses agreed that with PIK, nursing documentation is more complete (10 nurses), legibility is better (9 nurses), and that the quality of documentation is better (8 nurses).63 However, Ammenwerth and colleagues did not tie these findings to patient outcomes or changes in nursing practice. The conclusion that the introduction of a care planning system alone, without supporting organizational change, will not work is also supported by Spranzo’s64 work.

In summary, the nurse care planning literature indicates several things. First, when thought goes into the care planning process, better patient outcomes are possible. Second, altering the care planning process has thus far been done in an ad hoc manner and most of the evidence is from case studies. Individualized approaches have been implemented in specific settings. Their replicability across patient care settings, even from acute care to stepdown units within one hospital, has not been tested. While supporting the continuity of care on an individual unit is good, the larger issue of increasing continuity of care across time and space (across units and health care settings) needs to be addressed if patients are to receive truly holistic care. Third, current approaches to care planning have focused primarily on the care planning document itself. While some studies52, 53 have changed the care planning process, the focus has been the actual plan. Finally, when the care planning process has been computerized, there appear to be substantial system problems resulting from a lack of nursing input into the module’s design and functionality.30 Lack of nursing input has contributed to the failure of the nurses in these studies to embrace care planning and, at times, even to be able to judge whether a different care planning approach would result in better patient outcomes.

Towards an Interdisciplinary Plan of Care

Given the problems in developing a care planning system that works well for just nurses, it is clear why creating comprehensive systems that support interdisciplinary plans is that much more complicated. This is particularly true if Gage’s65 conception of interdisciplinary teams is utilized. He defines multidisciplinary teams as those in which consultation is a series of individual consultations, where interpretation is made independently by members of the medical team. On the other hand, interdisciplinary care planning occurs when the team collaboratively synthesizes the information and reaches consensus around treatment and goals for the patient. Much of the literature falls short of Gage’s ideal and what is categorized as interdisciplinary care planning should more appropriately be viewed as case management.

The majority of articles on interdisciplinary care planning focus either on case management or clinical pathways. These emanate from specialties and areas that traditionally have had closer ties among a variety of professionals (doctors, nurses, social workers) to manage a patient’s condition. Typical among the case management genre are case studies of interdisciplinary care planning in nursing homes66 or for the elderly.67 The clinical pathways articles focus on a specialty or specific unit, such as acute care.68 In one qualitative study of an interdisciplinary discharge planning process, Atwal69 found that many parts of the discharge process were regularly ignored and assessments were not done collaboratively. Nurses mentioned lack of time as the biggest barrier to interdisciplinary collaboration. Interdisciplinary care planning and the resulting plan can bring value to patients and enrich all disciplines; however, in its current iteration the vision proposed by Gage has not yet become a reality.

Practice Implications

Though the literature in this area lacks generalizability, there are a number of important implications that can be drawn. First, the enormous variability in the documentation and care planning practices exposed in this literature is a serious problem in and of itself. Given patients typically receive care from a variety of points across the health care system, moving from place to place where record content and format is variable, renders current medical records virtually useless in supporting patient-centric care in day-to-day practice. Moreover, information about a patient, once recorded, is either not accessible or—if available—is often in an unstandardized format (e.g., clinicians’ own words), resulting in countless errors of omission, misinterpretation, and redundancies in care. So too, most care planning methods are considered to bring little value and suffer from the same problems of poor design, poor accessibility, and no standardization. The lack of utility of the medical record in day-to-day practice begs the moral issue of whether the cost of maintaining the record in its current form (approximately 15 percent of a nurse’s time) is justified. The dollars spent on maintaining the “broken medical record” would bring more value if shifted to fund developing and refining industrywide solutions to repair the broken record. Further, the literature suggests that to compensate for poor record keeping systems, clinicians develop individualized shadow methods (scraps, also not standardized) to assist with organizing what each believes to be key information needed to carry out patient care. Since these information practices are nurse-centric and therefore variable, shadow methods further impede the flow and easy accessibility of patient information that promotes care continuity, quality, and safety.

Finally, there are valid instances of successful education interventions that improve aspects of documentation and care. The examples, however, are all locally focused and consequently also do little to fix the broken medical record. We see the broken record as a serious and costly problem to the health care industry and one that deserves a patient-centric industrywide solution. There were no studies of industrywide solutions noted in the literature. Until there is a true commitment to developing and refining industry-wide solutions that ensure accurate and comprehensive documentation, facilitating patient-centric care, the improvements that are possible in the areas of safety, cost, quality, and continuity will not be fully realized.

Research Implications

The research imperative for further study of this problem is manifested by the current state of the medical record and the high cost being incurred to maintain it. One approach to improve medical records is a patient-centric approach, which redesigns the recordkeeping system, and that will automatically ensure that the continuity, quality, and safety of care are a primary focus. From this review, there are several key questions that need methodologically rigorous research:

  1. How does variability in documentation impact patient outcomes?
  2. What are the key components of an effective documentation process that is patient centered and improves the transfer of information among clinicians and across settings of care?
  3. What aspects of documentation are shared among an interdisciplinary team, and what contributions to the patient record can each team member effectively provide?
  4. Should documentation vary across settings of care?


The evidence reviewed in this chapter suggests that formal recordkeeping practices (documentation into the medical record) are failing to fulfill their primary purpose, of supporting information flow that ensures the continuity, quality and safety of care. Moreover, disproportionate attention to secondary purposes (e.g., accreditation and legal standards) has produced a medical record that is document centered rather than patient focused. Cumbersome and variable formats, useless content, poor accessibility, and shadow records are all evidence of the extraordinary failure of the medical record. Given the exorbitant cost of the record and urgent need for tools that facilitate the flow of patient-centric information within and across systems, it is imperative to develop broad-based solutions.

Case Study: The HANDS Initiative and Plan-of-Care Method

The HANDS method is an intervention currently being refined to bring a strong patient focus to the medical record by replacing current forms of care plans with a single, standardized plan and related plan of care processes. The method addresses the needs, uncovered in this chapter, for summary patient care information that is standardized, meaningful, accurate, and readily available to all clinicians involved in a patient’s care across time and space. The HANDS method embodies the concepts and characteristics of high reliability organizations and as such is fixated on ensuring the continuity, quality, and safety of patient care (See Figure 1: HANDS Method Framework).

As depicted in the framework, the central thrust of the HANDS plan-of-care method is to facilitate clinician behaviors (mindfulness) and communication (heedful interrelating) that form the basis of a collective mind among the clinicians (interdisciplinary team) involved in a patient’s care. Organizations and systems factors must be aligned to support the mindfulness, heedful interrelating, and collective mind. The precursors to implementation of HANDS include culture readiness and a commitment to adopt and sustain the HANDS method (i.e., a commitment to change). Culture readiness is defined as an organization or system with an infrastructure that supports change and continuous learning, and is characterized by high levels of trust among its members and expectations that clinicians will engage in activities promoting mindfulness, heedful interrelating, and collective mind. Organization or system commitment to change is manifested by an organization or system formally adopting the HANDS standardized method for systemwide use, and by providing the necessary resources to educate, implement, and sustain the method across time. Finally, as is noted in the model, the patient care outcomes to be achieved by using HANDS and enabling mindfulness, heedful interrelating, and collective mind are safety, continuity, quality, and evidence based.

Earlier in this chapter, evidence from studies on nursing documentation and care plans as well as on interdisciplinary plans of care is presented and synthesized into a framework for the HANDS method. The method is an intervention that addresses the need for broadly based standardization of key aspects of documentation and communication, to facilitate patient-centric information flow. HANDS standardizes the plan-of-care documentation and processes, replacing the current widely variable forms, to support interdisciplinary decisionmaking that is based on shared knowledge among the clinicians. In this section, the history and future plans for the ongoing refinement of the HANDS method are presented.

This second part of the chapter focuses on the history of the HANDS Initiative and ongoing testing and refinement of the standardized plan-of-care method to date and future directions. The initiative addresses the gap previously identified in indicating the need for clinically relevant and patient-centric documentation and communication tools that support the collective mind (shared understanding) of the many clinicians involved in a patient’s care across time and space. The project formally began in 199870 with the main purpose of bringing visibility, utility, consistency, and accessibility to the nursing portion of the interdisciplinary plan. As was previously noted, nursing care plans generally have brought little value in day to day practice due to the wide range of formats, lack of individualization and accessibility, and the infeasibility of keeping them current. During the initiative’s early years the primary focus was on “perfecting” the format of the plan-of-care document through enabling technology and standardization. Through iterative refinement under real world conditions, we have learned that care plans, regardless of the quality of the document, bring little value unless they are an integral part of clinician-to-clinician (intra- and interdisciplinary) communication, serving as the basis upon which a collective mind among clinicians about a patient’s care is formed. Our ultimate vision is to standardize the documentation and communication of a useful and dynamic interdisciplinary plan of care that is patient-centric, available, and used everywhere. In the following section, pertinent background information is presented, followed by a summary of the HANDS project accomplishments to date, future plans, and conclusions.

History of HANDS

The project began when our team of researchers attempted to use existing vendor software products to collect a nursing dataset coded with standardized terminologies, for a study of the Nursing Outcomes Classification in the mid-1990s.71,72 The terminologies had been developed for the main purposes of representing nursing in health care databases and generating comparable nursing data for evaluating nursing practice. At the time, however, it became very apparent that, because of the wide variation in the practices used by vendors to integrate the terminologies into their systems, data was not comparable and frequently not retrievable. The HANDS initiative was thus born to remedy this situation and a prototype automated plan-of-care system with a database architecture that supported the generation of comparable nursing data was developed. It was clear to us, then and now, that the use of standardized terminologies alone is insufficient to produce comparable data. Instead, comparable data is generated when the same types of information are gathered at the same time intervals, using the same standardized response sets (standardized terminologies), same database architecture, and the same rules of data entry.

Standardized Nursing Terminologies

Since the late 1970s, efforts have been underway to identify nursing content and develop a means of representing it in computerized national health databases and clinical documentation systems. Werley and Zorn73 first described a minimum set of elements needed in Nursing Minimum Data Sets, and they noted that content (terminologies) would need to be developed to represent the nursing-specific items of diagnosis, intervention, and outcome. It was projected that collection of the elements represented by standardized terminologies would provide comparable data that allowed multiple uses (e.g., describe, evaluate, trend, and benchmark nursing practice).73 Subsequently, a number of terminologies have been developed to serve as response sets for nursing diagnosis, outcomes, and interventions. It is currently the purview of the American Nurses Association (ANA) Committee on Nursing Practice Information Infrastructure to set recognition criteria and formally recognize those terminologies meeting the established criteria. Over the years, the recognition criteria have been expanded and revised to align with the improvements in methods and tools for generating computable concept representations.74 Unfortunately the Committee’s actions have inadvertently confused the nursing constituency and thwarted progress toward achieving the vision of collecting comparable nursing data.

Since the early 1990s, the Committee on Nursing Practice Information Infrastructure has recognized more than one terminology (response set) for each of the data elements (diagnosis, intervention, and outcome), thus causing potential adopters to ask the question, “How are we going to get standardized data if nurses use different standardized languages?” The more recent recognition of entities (e.g., Systematized Nomenclature of Medicine Clinical Terms [SNOMED CT], and ABC Codes) that encompass content from the originally recognized nursing terminologies (NANDA, NOC, NIC, Omaha System, Perioperative Nursing Data Set, Clinical Care Classification, International Classification on Nursing Practice) has begged the question of how we are to use these recognized entities to achieve our professional goal of generating comparable nursing data. In truth, it is not clear how the 12 ANA recognized terminology entities can be used to generate comparable nursing data.75

The Terminology Solution in HANDS

From the beginning the HANDS project team grappled with how to create a long-term strategy that would generate professionwide, comparable nursing data when there was no professionwide commitment to a single terminology system. Given the circumstances of the time, we realized that professional consensus around a single terminology system was unlikely to occur in the absence of real time testing that demonstrated the value. We thus selected the terminology system with the broadest applicability—and that possessed characteristics indicative of its potential to grow and evolve over the long term—to be included in the HANDS method. The terminology system includes what is now called NANDA Classification,76 NIC,77 and NOC78 to represent the diagnosis, intervention, and outcome data elements respectively gathered in HANDS. All three of the terminologies have infrastructures in place to maintain and evolve the terminologies across time. The NANDA, NOC, and NIC (N3) terminologies provide comprehensiveness of terms, in that each includes terms to describe care in all types of settings. Additionally, all have been developed through research involving literature review and the extensive input of large numbers of nurses.

The rate of diffusion of a new language can be accelerated by defining a clear direction and taking action. For example, usage of N3 in the 43 nursing programs in Michigan substantially increased from1997 to 2001 following a resolution by Michigan Nurses Association to support N3 use in the State. NANDA usage remained high in 2001, with 92 percent of the schools of nursing (community college and university programs) indicating use. NIC usage rose from 22 percent to 58 percent and NOC usage rose from 0 percent to 58 percent between 1997 and 2001.79

Finally, there are several other points of evidence worth mentioning that indicate the long-term viability of the N3 terminologies within the nursing community at large. First, the N3 terminologies form a subset of SNOMED CT, the comprehensive clinical terminology. The SNOMED CT terminology is recognized by the National Centers for Vital and Health Statistics and the Consolidated Health Informatics Initiative as an acceptable standard for the Federal Patient Medical Record Information effort80 and is an ANA recognized terminology.75 Though nursing-specific terminology content is available in SNOMED CT, it is not the purview of SNOMED CT to keep the content current. Rather, the responsibility falls to nursing entities (terminology developers) to ensure that the quality and comprehensiveness of the terminologies is sustained and improved across time.

The N3 terminology developers are already taking responsibility for ensuring that the content is updated regularly, and that the terminology structures evolve in alignment with accepted standards for computable concept representations. As was previously noted, all three have strong internal structures for maintenance and updating of these terminologies, which have been in place for over a decade. The ongoing maintenance and support for NIC and NOC are provided through the University of Iowa-based Center for Nursing Classification and Clinical Effectiveness. To date, NIC has been translated into eight foreign languages and NOC into seven, indicating a growing international acceptance of these terminologies.81 The ongoing maintenance and development of NANDA are provided by the NANDA International office at gro.adnan@ofni. Every 2 years a joint N3 international conference is held at a central location in the United States to promote crosspollination of ideas that support continuous diffusion of these terminologies both nationally and internationally.

Another indicator of the long term viability of N3 is its growing and extensive presence in the literature. The technique for measuring such presence, bibliometrics, has been used in health care to evaluate the extent and rate of diffusion of an innovation.82 For purposes of this chapter, a systematic search was conducted (with the help of CINAHL® personnel) to identify numbers of journal articles, complete books, and proceedings in which some aspect of the ANA-recognized, “nursing developed” terminologies (nursing content only) were a “major focus” between 1996 and 2006. The results appear in Table 3, and are organized by the nursing terminology system defined as providing terms for the data elements of nursing diagnosis, intervention, and outcome. Using this definition, there are five currently recognized ANA nursing terminology systems in addition to N3: the International Classification on Nursing Practice, the Omaha System, the Perioperative Nursing Data Set, the Clinical Care Classification, and (formerly) the Home Health Care Classification. Though the results must be interpreted with caution, it is readily apparent that there are major and substantial differences in the number of literature entries and trends between the N3 system and the others. Moreover, the number of entries for N3 appears to be growing rather than diminishing. Further analysis and interpretation of the findings will be presented in a forthcoming manuscript. Also of note is that the HANDS research conducted to date is providing evidence that N3 can be successfully integrated into a standardized, technology-supported care planning method, and generate comparable data to evaluate nursing practice.

Table 3

Table 3

Number of CINAHL “Major Focus” Entries for the 5 ANA Recognized Nursing Interface Terminology Systems 1996–2006

The HANDS Initiative: Phase 1

Phase 1 of the HANDS project emerged in response to the absence of a path that would lead to the collection and generation of comparable nursing data. In this phase, our team focused on creating a standardized prototype of a dynamic, technology-supported plan that would generate comparable data. Our vision, then and now, is to evolve a useful care planning method that standardizes both the plan and the planning processes, is used widely, and generates standardized and comparable data for identifying and disseminating best practices. For a more specific account of the prototype development, see Keenan and colleagues70

In creating the original HANDS prototype, the team made a deliberate choice to incorporate the N3 terminology system to represent the data elements of clinical (nursing relevant) diagnosis, interventions, and outcomes for the reason described above. The initial HANDS work thus focused on perfecting a tool that could be used to document the plan and generate comparable data. The teams’ efforts focused on the plan format, database, and rules of data entry. The approach matched the assumed need for such a tool with the availability of the means, including the technology and terminologies.83 It was believed that the tool would help meet the vision of the HANDS.

Version 1 of HANDS (single user application) was initially implemented and tested in one intensive care unit. A sociocultural approach, putting our users front and center, was used to gain an understanding of the impact of the HANDS technology on nurses’ work practices.84 Many qualitative and simple quantitative methods were employed and repeated across time in our evaluations, and the results were added to improve the HANDS tool and processes through iterations of the design, test, and refine cycle. Our methods included observations, surveys, focus groups, “think-alouds,” analysis of individual use patterns available in transaction logs, and routine checks of term meaning reliabilities and NOC outcome ratings.

The findings85 gathered from the multiple methods in the pilot study helped uncover a number of issues with the technology that were not always apparent to our nurse subjects and permitted us to implement remedies. Most importantly we learned that our initial approach was document-centric. And although our method improved compliance and satisfaction with the care planning documentation, it did little to promote the collective mind of the clinicians involved in care. In fact, we found that many of the individual nurses religiously and mindfully updated plans of care in isolation. Rarely did nurses use the plans to guide clinician-to-clinician transfer of information. In retrospect, this finding was understandable and echoed the evidence reviewed in this chapter, that the plans have typically brought little value in day-to-day practice. Expecting nurses to use plans in more patient-centric, rather than document-centric, ways without educating them about how this might be done is unlikely to bring about the desired change. These results were used to refine the software and revise the rules and training for Phase 2 of the HANDS research initiative.

The HANDS Initiative: Phase 2

In preparation for this phase, the HANDS tool was converted to a Web-based application. WEBHANDS allows the clinician to easily enter and update a patient’s plan from any terminal on the unit. Since the plan-of-care histories are stored on a central server, clinicians involved in a patient’s care also have ready access to the history of the patient’s plan from previous episodes. This information provides the clinician an “at-a-glance summary” of the issues that have been addressed through the care provided by the health care team, and progress toward outcomes across time. The improvements in the software accessibility were expected to streamline the documentation of the plan of care and make it easier to integrate the plan into handover communication (intradisciplinary heedful interrelating)

Phase 2 research built on lessons learned in Phase 1, as well as the integration of evidence on communication, handovers, and behaviors characteristic of high reliability organizations. There are two major aims of this 3-year, multisite study of the HANDS method, HIT Support for Safe Nursing Care, funded by the Agency for Healthcare Research and Quality.86 The aims include demonstrating that standardization of the HANDS method can be maintained across multiple diverse sites and that that the method fosters mindfulness, heedful interrelating, and collective mind as described in our framework presented earlier in the chapter. As can be seen, our emphasis moved from a document-centered to a patient-focused plan-of-care method that encompasses both the plan and the planning processes.

In the study, the HANDS method is implemented and fully evaluated on the participating units. Nurse champions are first identified and educated (40 hours: combination of in class, and independent study). The champions, in turn educate the remaining nurses employed on the unit (6 hours: 2 hours of classroom, 4 hours of independent study). A greater emphasis was placed on educating nurses to engage in heedful interrelating during handovers in this phase of our research. At this writing, we have just entered year 3 of the study and all units are fully live with the HANDS plan-of-care method. Nurses are required to enter admission or update care plans on all patients and to use the plans to structure communication at every handover.

Similar to our pilot phase, we are using multiple and repeated methods of evaluation and have already analyzed and integrated early findings into the tool and method.87, 88 Thus far, we have demonstrated that standardization of care plan entry, storage, and retrieval can be maintained across the eight participating diverse units with the HANDS software tool. As in the pilot unit, nurses have reported high levels of satisfaction with the tool and are nearly 100 percent compliant in entering admission and update plans on all patients at every handover. Still needing improvement is the use of the plan at handovers (heedful interrelating). From interviews with nurses from our four first-year study units, we learned that there was wide variation in how nurses used the plans in the handover, and this was thought to add little value.88 So, too, nurses complained that the most current plan was not always readily accessible for the handover. To remedy the situation, the nurses recommended developing a consistent format for handovers and creating easy access to the most current plan via the computer. The feedback was used to improve the software and plans of care were made readily available to the nurse via the patient list screen. In addition the SHARE (S-ketch, H-ANDS, A-ims, R-ationale, and E-xchange) structure was devised to help nurses uniformly integrate the plan of care into the handover process and both were added to the training of nurses in our year-2 study units.88

At this writing the four year-2 sites have been live with the revised HANDS method for nearly 4 months and, as with the year-1 sites, indicate satisfaction with the tool and almost 100 percent compliance with entering plans as directed. Nonetheless, even with the new enhancements, issues are surfacing that indicate that the revamped handover process is not yet fully working as expected. Further study of this issue is planned to determine how the handover communication can be improved. Intervention will then be devised and tested in an effort to improve heedful interrelating through our continuous learning model. In addition, we will complete our planned data collection, which will allow us to more thoroughly evaluate mindfulness and the impact of the HANDS method on the safety culture and error rates.

Future Plans for HANDS

Even without completing the full evaluation of the HANDS method in the current study, findings to date suggest several next steps. First and foremost, the study has provided evidence that the HANDS method is valuable and stable and should be considered for fuller adoption. This is because most of the benefits of the method can only be realized through widespread adoption and use, which motivates commitment that cannot be achieved when only one or two units in a system have adopted the method. For example, plan-of-care histories are not readily available unless all units in the system are using HANDS. Nurses also are reluctant to change comfortable (though variable) handover routines to embrace standardization before there is a full organizational commitment to the standardization. So, too, without widespread adoption and use of the method, it is difficult to identify best practices and disseminate these to the practitioners at the point of care through HANDS infrastructure. As is noted in our framework, depicted in Figure 1, the level of success of HANDS is integrally connected to the level of commitment to the change by the overall organization. For this reason we are encouraging organizations who express interest and readiness to adopt HANDS, to commit to full organization and adoption of the HANDS method.

We also see the need to formally position the HANDS method as an interdisciplinary initiative. As was noted in the previous sections’ conclusions, there is a pressing need for tools that support the collective mind of the entire interdisciplinary team around a patient’s care. The HANDS method already includes a number of features that can be easily adapted to accommodate the needs of the interdisciplinary team members. At this time a future study is planned to collaborate with physicians on refining the method for interdisciplinary use.

Finally, the method has been designed to work in and across all types of settings where patients seek care. To bring the intended value the method must work regardless of the Clinical Information System (CIS) adopted within the institution. We have begun planning the development of a universal connector that will allow HANDS to seamlessly connect to an organization’s CIS regardless of the vendor types. In addition, other studies are underway to determine how to make HANDS available for immediate and widespread use. Of deepest concern and the direction of the team’s passion and efforts is achieving our longstanding vision for health care.

Even without completing the full evaluation of the HANDS method in the current study, findings to date suggest several next steps. First and foremost, the current study has provided some evidence that the HANDS method is valuable and stable and should be considered for wide scale adoption. This is because most of the benefits of the method can only be realized through wide scale adoption and use that motivates commitment that cannot be achieved when only one or two units in a system have adopted the method. For example, plan of care histories are not readily available unless all units in the system are using HANDS. Nurses also are reluctant to change comfortable (though variable) handover routines to embrace standardization before full organization commitment to the standardization has been established. So too, without widespread adoption and use of the method it is difficult to identify best practices and disseminate these to the practitioners at the point of care through HANDS infrastructure. As is noted in our framework, depicted in Figure 1, the level of success of HANDS is integrally connected to the level of commitment to the change by the overall organization. For this reason we are encouraging organizations who express interest and readiness to adopt HANDS, to commit to full organizational adoption of the HANDS method.

It could be important to formally position the HANDS method as an interdisciplinary initiative. As was noted in the previous section, there is a pressing need for tools that support the collective mind of the entire interdisciplinary team around a patient’s care. The HANDS method already includes a number of features that can be easily adapted to accommodate the needs of the interdisciplinary team members. Finally, the method has been designed to work in and across all types of settings where patients seek care. As such, to realize the intended value, the method would need to be effectively integrated in all clinical information systems across institutions.

Search Strategy

The areas covered in this literature review were nursing documentation and care planning. The literature cited in this chapter was identified in several ways. The medical and nursing literature on care planning, standardized terminologies, documentation, and quality indicators has been reviewed, selecting and retaining only those references that pertain to this work in some way regardless of the quality of the evidence. Additionally, a comprehensive search of the health care and organizational behavior literature was conducted, from 1996 to 2006 in MEDLINE® (using the OVID interface), CINAHL®, Cochrane Library, PubMed®, Dissertation Abstracts International, and Business Source Complete (EBSCO) to find high quality evidence available on nurse care planning and documentation. The main MeSH® subject search terms included continuity of patient care, documentation, medical errors, nursing records, patient care planning, and quality indicators–health care. A successive fractions search strategy was employed—a large selection of articles was made and then this was pared down to create a subset of the most applicable articles. To generate a large collection of potentially appropriate articles, each subject term was searched with minimal parameters from the subject heading; generally methods, standards, trends, and utilization were selected generating 9,422 matches. The additional limits of clinical, controlled, and randomized controlled trials (English) were set, producing a total of 118 matches.

Review of the 118 studies revealed that a number were not pertinent. For example, none of the 22 patient care planning articles pertained to nurse care planning. Only 3 of the 31 documentation articles were relevant. Many of those in the overall category of documentation were general and did not pertain to nursing. Also documentation often referred to research data collection or some other intervention, and not to patient care documentation. Consequently the results of the three searches (patient care planning AND nursing records, patient care planning AND documentation, and nursing records AND documentation) were reviewed to identify other pertinent studies, largely evaluative in nature. In these secondary searches, articles by anonymous authors, foreign language materials, commentaries, letters, 1–2 page articles, and those that were out of scope were eliminated. The resulting summaries of these articles appear in two evidence-based tables. Table 1 includes 17 studies representing the literature associated with recordkeeping quality, including studies evaluating completeness, accuracy, and timeframe of documentation. In Table 2, 22 articles are included describing research aimed at improving documentation and care planning practices.

Table 1

Table 1

References Associated with Recordkeeping Quality (Completeness, Time)

Table 2

Table 2

References associated with Improving Documentation and Care Planning Practices


We wish to acknowledge the AHRQ funding support for the 3 year study entitled HIT Support for Safe Nursing Care, 7-R01 HS01 5054-02.


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