Date of Award
Spring 1988
Document Type
Thesis - Restricted
Degree Name
Master of Science (MS)
Department
Nursing
Abstract
Nursing documentation in long term care is an integral part of the resident care process. The health care team uses it as a tool to communicate and document the nursing care given, the utilization of the nursing process, and the residents' attainment or lack of attainment of goals. A complete description of the residents' status and responses to medical and nursing care, which should be easily retrievable, should be found in the nursing documentation. The State of Wisconsin surveyors use nursing documentation to determine the residents' level of acuity, which determines the amount of reimbursement given to the facility for each resident, and to monitor the execution of state standards of care. Review of the literature provided a comparison of the narrative, problem oriented, and focus charting systems. Adaptation of the focus charting system incorporated all the components required to fulfill the needs of nursing documentation in long term care.
Recommended Citation
Zeitlin, Sandra, "Selection, Adaptation, and Implementation of a Documentation System for Long Term Care" (1988). Master's Theses (1922-2009) Access restricted to Marquette Campus. 3624.
https://epublications.marquette.edu/theses/3624