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Improving Nursing Documentation in a

Computer-based Inpatient Hospital Setting


Dawn Gapko  RN, BSN




Today, nurses not only have to provide high quality patient care, they are required to document everything from past medical history to whether or not the patient wants his or her pastor notified of the admission.  With stringent rules and regulations passed by Medicare and Joint Commission on Accreditation of Health Care Organizations, nurses struggle with the requirements that are put upon them to document complete and accurate patient information.  As nurses enter into the era of computerization, it is important that nurses focus their efforts on improving nursing documentation through the use of computers instead of creating more work for themselves.  This article shares what a small rural hospital did to assist in improving nursing documentation through the use of computers at the patientís bedside.


Key Words:  Computer, Nursing, Documentation, Quality, Patient Care