Evaluation and Optimization of an Inpatient Daily Cares Flowsheet

Clinical documentation is one of the highest priorities of any clinician. Documentation is only second to the actual care of the patient and could be considered another dimension or extension of patient care (Andrews & St Aubyn, 2015). Ask any clinician about the importance of clinical documentation, and you might hear the common phrase "If it is not charted, it didn't happen" implying the importance for clinicians to document everything. Without care documentation, we can't know all that we have done for a patient, and without knowing what we have done, we can't know what we need to do. Over time, the process of patient care documentation has evolved from paper charting to its current state of electronic charting systems, a common functionality in electronic health records (EHRs). Current EHR systems use several different documentation techniques, but flowsheet documentation is very common. The primary objective of this project is to focus on the most commonly use flowsheet among all clinicians, the Daily Cares flowsheet. The Daily Cares flowsheet is a flowsheet used to document acts of daily living (ADLs) the patient and clinician have or have not performed for the patient's ultimate recovery and well being during their hospital stay.