PMID: 11930595Apr 5, 2002Paper

Documentation of care outcomes in an academic nursing clinic: an assessment

Journal of the American Academy of Nurse Practitioners
A L DavisK H Sousa

Abstract

To assess documentation of client data collected at an academic nursing clinic using the Wilson and Cleary Health Related Quality of Life (HRQOL) conceptual model as a framework. A chart audit of 100 randomly selected active client records was conducted. Although several significant HRQOL variables were documented, data regarding general health perception and quality of life were not present. The HRQOL conceptual model provided an appropriate structure for evaluating the documentation. Further effort must be made to include key HRQOL dimensions in the clinic's documentation system. Documenting the quality of care provided in nursing clinics is essential in order for other professionals and the public to recognize nursing professionals as accountable and credible. This project formed the basis for a computerized outcomes-based client record system.

References

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Citations

Aug 22, 2003·Journal of the American Academy of Nurse Practitioners·Karen H SousaElizabeth Jordan Holman
May 22, 2010·International Journal of Nursing Practice·Diana JefferiesRhonda Griffiths

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