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J Nurs Care Qual. 1996 Jul;10(4):66-77.

Streamlining documentation: an opportunity to reduce costs and increase nurse clinicians' time with patients.

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Marcella Neihoff School of Nursing, Loyola University, Chicago, Illinois, USA.


Clinical documentation can take up to 25 percent of a nurse's time in an acute care setting, not to mention the time spent by other clinicians and ancillary caregivers on documentation. Institutions can reduce documentation time by systematically determining what information is crucial to the provision of patient care across all disciplines and then using a redesign process that mirrors work redesign. By following a structured process that challenges the philosophy and function of the documentation system, a hospital's multidisciplinary staff members can use their expertise to design alternatives that achieve documentation's original intent-to document diagnoses and treatment accurately-in a more efficient and useful way.

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