Documentation and the Care Planning Process
Chapter 49. Documentation and the Nurse Care Planning Process
Gail M. Keenan, Elizabeth Yakel, Dana Tschannen, Mary Mandeville
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 Handson 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...