Standardization of nursing documentation and its effects on patient outcomes

Here is a search strategy that finds 13 articles in PubMed. Go here, click on PubMed, and run this search. Then you can click the Find It at Emory button within an article’s entry to see if Emory has full-text access for an article.

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Here are three articles that state that standardized documentation improves patient outcomes. The others seem to only briefly mention that standardizing documentation may improve patient outcomes. However, they may give you ideas on how to best standardize documentation.

Huffman, Melinda H, and Jennie ACowan. “Redefine care delivery and documentation.” Nursing Management 35.2 (2004):34-8.

Müller Staub, Maria, et al. “Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study.” International Journal of Nursing Terminologies and Classifications 18.1 (2007):5-17.

Müller Staub, Maria. “Evaluation of the implementation of nursing diagnoses, interventions, and outcomes.” International Journal of Nursing Terminologies and Classifications 20.1 (2009):9-15.

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About Lisa

I have been a Clinical Informationist (aka Medical Librarian) for Emory University since September 2013. Prior to that, I was a Medical Librarian for Lincoln Memorial University (LMU) from March 2007 to August 2013 and served its DeBusk College of Osteopathic Medicine (LMU-DCOM), Caylor School of Nursing, and allied health programs. From January 2002 - March 2007, I served the Medical Assisting (MA), Occupational Therapy Assistant, Physical Therapy Assistant, Radiologic Technologist, and Nursing programs at South College in Knoxville, Tennessee. I graduated from The University of Tennessee School of Information Sciences with a Master of Science degree in December 2000. Received a Educational Specialist (EdS) degree in Educational Administration and Supervision with a higher education focus in August 2010 from LMU.

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