Improvement and Standardization of Nursing Documentation: Methods and Effects

Objective To improve and standardize the charting and management of nursing documentation and to improve the efficiency and quality of nursing care.Methods Nursing documentation was standardized as well as simplified by integrating and simplifying the flowsheets,standardizing the contents of documentation,and changing the pattern of charting.Results The nursing documentation was more objective,real,accurate and timely,and the charting time in general wards was 28.3 minutes by every shift with a reduction of 37.5 minutes,and in critical care units 56.8 minutes with a reduction of 54.8 minutes.The quality of nursing care improved with more direct care time.Conclusion To ensure the quality of nursing documentation,training should be strengthened to improve nurses' ability to effective charting and collaborations among healthcare professionals be facilitated to provide accurate content.Meanwhile,monitoring and supervision should be enhanced to continuously improve the quality of nursing care.