Development of a goal-directed nursing admission history

This was a descriptive study of the process required for the development of a goal-directed data base. Outcome goals for a nursing admission history were identified during phase one of the development process. Following the development of the decisions for the data base, criteria for each decision were identified during phase two. These criteria addressed the procedural mechanisms and actual content of the data base. The data base development took place at phase three. Specific data items which fulfilled the requirements of the criteria identified in phase two legal and governing agencies and hospital and nursing requests were identified. These data items were compiled into a widely accepted general format for nursing admission history. At phase four, computerized alerts were designed for the departments of social services, dietary, drug and alcohol rehabilitation, clergy, enterostomal therapy and coordinated rehabilitation services. The content of each department's alert was reviewed and accepted by each department director.