Evaluating two different methods of documenting care plans in medical records

Abstract

Evaluates care plans documented in two different ways, using controlled and randomised studies of consecutive acutely admitted medical patients. Within 24 hours after admission, a care plan was made for the hospital stay, specifying active problems, a plan of action and a time‐schedule. In study 1, patients had care plans written directly into their medical records during the intervention period, while the normal admittance procedure was followed in the control period. In study 2, all patients had a care plan made on a planning form and in the medical record. Patients were randomised either to have the form stay in the medical record or to have it removed. Study 1 results showed that care plans were associated with earlier recognition of patients’ active problems, whereas the tendency to initiate solutions to active problems earlier was insignificant. Length of stay (LOS) and risk of readmission remained unchanged. In study 2, planning forms were associated with a 1.5‐day lower LOS and higher accuracy of planned LOS. Risk of readmission and accomplishment of plans of action were unaltered.

Citation

From, G., Pedersen, L.M., Hansen, J., Christy, M., Gjørup, T., Thorsgaard, N., Perrild, H., Bonnevie, O. and Frølich, A. (2003), "Evaluating two different methods of documenting care plans in medical records", Clinical Governance: An International Journal, Vol. 8 No. 2, pp. 138-150. https://doi.org/10.1108/14777270310471621