Computerized documentation of case management. From diagnosis to outcomes.

Abstract

Documentation of patient care, outcomes, and report writing are important aspects of the role of the case manager. In this article, the author examines the types of documentation approaches used by nurses in recent years and the new applications called for in the case manager role. Issues such as standardized language and multidisciplinary documentation are explored. Approaches to examining computerized documentation systems are presented. Finally, the importance of documentation in demonstrating what nurses do, allowing comparison of outcomes, and supporting reimbursement for nurses, are discussed.