Effective Documentation Tools

Abstract

Quality assurance programs provide a very effective means to monitor and evaluate medical care. Quality assurance involves: (1) Identify a problem; (2) Determine the source and nature of the problem; (3) Develop policies and methods to effect improvement; (4) Implement those polices; (5) Monitor the methods applied; and (6) Evaluate their effectiveness. Because this definition of quality assurance so closely resembles the Nursing Process, the health unit staff was able to use their knowledge of the nursing process to develop many forms which improve the quality of patient care. These forms include the NASA DFRC Service Report, the occupational injury form (Incident Report), the patient survey (Pre-hospital Evaluation/Care Report), the Laboratory Log Sheet, the 911 Run Sheet, and the Patient Assessment Stamp. Examples and steps which are followed to generate these reports are described.