Revitalizing a Documentation System

The nursing department of a 154-bed acute rehabilitation facility, cognizant of the changing trends in health care and responding to feedback from staff, developed and implemented a comprehensive documentation system. The previous system had been fragmented, inconsistent, and inefficient. The development of the new system focused on the complex needs of the rehabilitation client and the equally complex standards required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Commission on Accreditation of Rehabilitation Facilities (CARF), and insurance carriers. The final product, which was based on the nursing process and functional health patterns, encompassed the following areas from admission to discharge: providing feedback on clients' functional abilities and progress toward goals, satisfying requirements of the 1990 JCAHO standards, and, finally, using a flow sheet that saves nursing time and increases objectivity. This article describes the system from conceptualization to successful implementation.