Chapter 49. Documentation and the Nurse Care 

Planning Process 

Gail M. Keenan, Elizabeth Yakel, Dana Tschannen, Mary Mandeville 

Background 

Tools are needed to support the continuous and efficient shared understanding of a patient’s 

care history that simultaneously aids sound intra- and interdisciplinary communication and 

decisionmaking about the patient’s future care. Such tools are vital to ensure that the continuity, 

safety, and quality of care endure across the multiple handovers made by the many clinicians 

involved in a patient’s care. A primary purpose of documentation and recordkeeping systems is 

to facilitate information flow that supports the continuity, quality, and safety of care. Since 

recordkeeping systems serve multiple purposes (e.g., legal requirements, accreditation, 

accountability, financial billing, and others), a tension has arisen and is undermining the primary 

purpose of the record and instead fueling discontinuity of care, near-misses, and errors. Among 

the more specialized types of documentation is the plan of care, a requirement of the Joint 

Commission.1, 2 Though planning and plans should facilitate information flow across clinician 

providers there is little generalizable evidence about their effectiveness. 

In the first part of this chapter, evidence from studies on nursing documentation, care plans, 

and interdisciplinary plans of care is presented and synthesized into a framework for the Handson Automated Nursing Data System (HANDS) method. The method is an intervention that 

addresses the need for broad-based standardization of key aspects of documentation and 

communication to facilitate patient-centric information flow. HANDS standardizes the plan of 

care documentation and processes by replacing the current widely variable forms. It supports 

interdisciplinary decisionmaking that is based on the shared knowledge from clinicians. Finally, 

a case study presenting the history and future plans for the ongoing refinement of the HANDS 

method is presented. 

Research Evidence 

Recordkeeping Practices of Nurses and Nursing Documentation 

Information work is a critical part of the medical endeavor. Strauss and Corbin3 note that 

trajectory work, as they view medical care, requires information flow before and after each task 

or task sequence to maintain continuity of care. Tasks are not isolated but are intertwined and 

build on one another to achieve patient goals. Nurses bear a large burden in both managing and 

implementing the interdisciplinary team’s plan for the patient, as well as documenting the care 

and progress toward goals. As a result, nurses spend considerable amounts of time doing 

information work. There are several genres of nursing documentation studies: those that examine 

recordkeeping practices as a whole, those that examine issues relating to the documentation 

(time, content, completeness), and comparative evaluations of different types of changes in the 

documentation regime including automation versus paper. Taken together, these provide both 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

detailed and broad knowledge of nurses’ recordkeeping practices and highlight the reasons why 

any change (manual or computerized) is so difficult to integrate into nursing practice. 

General Recordkeeping Practices of Nurses 

Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, 

practitioners, and hospital administrators view recordkeeping as an important element leading to 

continuity of care, safety, quality care, and compliance.4–7 Studies, however, reveal surprisingly 

little evidence of the linkage between recordkeeping and these outcomes. The literature features 

multiple exhortations and case studies aimed at improving nurses’ recordkeeping in general8–10

or for specific diagnoses.11, 12 

The literature also reveals the tensions surrounding nursing documentation. These include: 

the amount of time spent documenting;13–15 the number of errors in the records;9,16,17 the need for 

legal accountability;18–20 the desire to make nursing work visible;21 and the necessity of making 

nursing notes understandable to the other disciplines.22, 23 For the purposes of this review, we 

confine ourselves to discussions of either manual or automated nursing systems of documenting 

patient care, primarily in hospitals. As we have found, while there are good and well-designed 

individual studies, the different methodologies, populations studied, and variables analyzed have 

led to little generalizability across the research, making comparisons between them impossible. 

There are several literature reviews of nursing documentation systems. Urquhart and 

Currell24 completed the most systematic and comprehensive review, examining the literature 

through 2004. They focus on nursing record systems as variations in the systems effect nursing 

practice and patient outcomes. Currell and Urquhart conclude that nurses experience tensions 

between patient care needs and hospital management-promoted documentation rules. They also 

found that the studies show both mixed responses to new systems and inconclusive links between 

the nursing documentation system used and its impact on patient care. Also noted was the lack of 

standardization among systems.25 

In a more targeted literature review, Langowski26 examined the relationship between quality 

health care, particularly safety, and point-of-care online nursing documentation systems. Unlike 

Currell and Urquhart,25 Langowski found that overall documentation quality improved with an 

online electronic health record (EHR). The measures used, however, varied between the studies, 

and documentation impact on quality was assessed through evaluating the presence of certain 

types of information and the frequency of data entry. The accuracy of the information was not 

evaluated. Nurses’ satisfaction with documentation systems has also been used as a measure of 

quality though the relationship between satisfaction and documentation is never clearly 

delineated. The variation in the definition and measures used for evaluating quality is 

characteristic of this literature. 

The final review was carried out by Karkkainen, Bondas, and Eriksson.27 They conducted a 

metasynthesis of 14 qualitative research reports to determine how well individualized patient 

care was represented in nursing documentation. Karkkainen and coworkers identified three 

themes in the literature reflecting the tensions in the record: demands of the organization, nurses’ 

attitudes and duties, and the patient’s involvement in care. This mirrors the findings of Currell 

and Urquhart. In conclusion, Karkkainen, Bondas, and Eriksson argue that individualized patient 

care is not visible in nursing documentation, and that current methods used to standardize 

communication in the records (forms with check-off lists) contribute to this gap. In another work, 

Karkkainen and Eriksson28 note that, although standardized forms of documentation can enhance 

concise and directed information, poorly designed forms may enhance document content but do 

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Documentation and the Care Planning Process

little to support patient-centric care. The challenge is to design systems that are patient focused 

but also reap the benefits of standardization in terms of more accurate, precise, and up-to-date 

information transfer among all members of the interdisciplinary team. 

Several single studies provide additional insight into nursing recordkeeping practices. Allen29

examined nurses’ views of the nursing record and its routine usage in practice. Using 

observations and interviews, Allen found that nurses were ambivalent towards the records, both 

seeing them as a symbol of the place of nurses in the clinical arena, but also reporting that the 

records are too heavily structured by management, a finding echoed throughout the literature 

(e.g. Lee and colleagues30). As a consequence, Allen points to the practice of nurses developing 

shadow documentation systems (informal nursing records and ward diaries) that help nurses 

maintain a high-level overview of the patient’s care on one’s shift. 

 In another qualitative study, Hardey and colleagues31 observed nurses in five acute elderly 

care wards at a district general hospital in the south of England. They argue that “scraps,” 

individualized information systems, contained a unique combination of personal and professional 

knowledge and changed dynamically in response to patient care on a shift. The main source of 

information in the scraps was information conveyed during the nurse handover. This finding 

suggests that scraps provide information not found in the patient record. Instead the scraps 

contain the summarized or synthesized version of the patient’s story that includes only the 

information the nurse feels is needed to carry out care effectively on one’s shift. 

Ngin32 picks up on the idea of information work as discussed by Strauss and Corbin3

 and 

provides an in-depth analysis of nurses’ retrieval, interpretation, documentation, and passing of 

information. She, too, found that nurses relied less on the formal forms of documentation in the 

medical record and the care plan than on informal sources; her subjects preferred getting 

information directly from other nurses who had first-hand, observational knowledge of patients 

or from summary documentation, such as in Kardexes or personal notes. Ngin quoted nurses as 

saying, “The Kardex is a ‘living document’ which nurses have dubbed the Bible of nursing care. 

On the other hand, nurses tend to regard care plans as ‘just a requirement’”32 (p. 81). Ngin also 

differentiates between coordination of care (which she saw as the role of the Kardex, various 

worksheets, and more personalized information systems) and continuity of care (which she 

viewed as sustained by handovers). 

In combination, these reviews and studies indicate that nursing documentation in the medical 

record does not meet the espoused purpose of being a communication tool that supports the 

continuity, quality, and safety of care. The evidence presented in this section also points to 

several conditions that perpetuate misunderstanding of nursing work and the means to track it. 

First, there is wide variation in recordkeeping practices between units and between health care 

organizations. Second, nurses heavily utilize shadow recordkeeping systems to aid in immediate 

patient care activities and decisions. Finally, there is an overwhelmingly negative attitude toward 

formal recordkeeping—either outright hostility or the view that documentation is “just a 

requirement.” 

Representativeness and Completeness of the Content 

In several more targeted studies, the central issues of concern were how well the records 

reflected the care given and accuracy of the patient’s condition. Tornvall and colleagues33

audited EHR records and found that reports of medical status and interventions were more 

prevalent than nursing status. The authors concluded that nursing documentation was limited and 

inadequate for evaluating the actual care given. Ehrenberg and Ehnfors’34 triangulation between 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

data from a chart review and interviews of nurses revealed little agreement between the records 

and the care nurses reported as having given. The researchers went so far as to state in their 

findings (p. 303) that “there are serious limitations in using the patient records as a data source 

for care delivery or for quality assessment and evaluation of care.”34

Another set of studies examined the completeness of nursing documentation; these typically 

utilized chart review and audit as a methodology. The issue of completeness is important; 

Croke35 cites failure to document as one of the six top reasons that nurses face malpractice suits. 

In terms of overall completeness, Stokke and Kalfoss36 found many gaps in nursing 

documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected 

outcomes were absent between 18 percent and 45 percent of the time. Taylor37 found that many 

of the care plans reviewed did not convey the specific information necessary to carry out the 

required procedure. One third of the nurses in this study mentioned accessing written 

documentation but did not express any preference for care plans.37 

Other completeness studies have evaluated the impact of the form type and content required. 

In a controlled clinical trial utilizing a chart review method, Sterling38 analyzed wound 

assessment documents from three different units. While more of the important details of wound 

assessment were recorded when using a wound assessment chart, missing information was found 

for both charting methods (conditions) in the study. In another controlled clinical trial with home 

care nurses, Tornkvist and colleagues39 administered an educational intervention focusing on 

pain management. Their findings indicated that several statistically significant improvements in 

care were achieved after the introduction of the pain-advisers in the study units. Most pertinent to 

this chapter, the nurses’ satisfaction with their written documentation on pain increased with the 

addition of several new types of assessments used for charting pain.39

While computerization has been referred to as a cure for incomplete records, the evidence on 

this is also mixed. Larrabee and colleagues40 found that completeness increases over time after 

system implementation, with expected gains not being realized until 1 year after implementation. 

Care planning systems are also not immune from problems with the completeness of 

documentation. While Bjorvell and colleagues41 reported increased completeness of 

documentation, particularly in the proportion of discharge planning notes, Griffiths and 

Hutchings’42 audit of records from home health care nurses found initial nursing assessments 

poorly documented, affecting later care. 

The studies in this section indicate two things. Completeness of a record may have an impact 

on the quality of care, but only if it reflects completeness of the right content. Echoed again here 

is that document focus, rather than the patient-centric nature of the medical record, does little to 

support shared understanding by clinicians of care and the communication needed to ensure the 

continuity, quality, and safety of care. The typical content and format of documentation—and its 

lack of accessibility—have also resulted in document-centric rather than patient-centric records. 

Time Spent Documenting 

Time spent documenting patient care is generally not regarded by nurses as being patient 

care, even though there is a Nursing Intervention Classification (NIC) term for it. Studies 

focused on time indicate that nurses spend a significant amount of time recordkeeping. In the 

most comprehensive literature review on time, Poissant and colleagues14 reviewed 11 studies 

examining documentation time before and after moving from a manual to an online system. Of 

these studies, six reported a time savings when using a computer. There was up to a 25 percent 

savings by nurses charting with bedside systems. Three studies reported increased time, 

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Documentation and the Care Planning Process

particularly in the one study that employed handheld computers. However, of the three studies 

that assessed nurses’ efficiency by using the patient as the sampling unit, the results were 

negative—more time was spent on documentation per patient after system implementation, with 

increases ranging from 7.7 percent to 128 percent. The authors propose that time efficiencies are 

gained by standardized forms in systems, although some systems require more information to be 

documented.14 

Other studies have exposed the overall documentation burden carried by nurses. Hardey and 

colleagues31 found that recordkeeping was given lower status and priority than was direct patient 

care. It was also viewed as excessively time consuming. Nurses regularly copied data from the 

medical record and other documents to create personal records that guided their activities. Korst 

and colleagues13 conducted a work-sampling study over a 14-day period. Out of 2,160 

observations, the average percent of time nurses spent on documentation was 15.8 percent; 10.6 

percent for entry on paper records and 5.2 percent on the computer. The percentage of time spent 

on documentation was independently associated with day versus night shifts (19.2 percent vs. 

12.4 percent, respectively). Time of day is also a factor in retrieving information. 

The series of studies in this section indirectly expose the cost implications of maintaining 

medical records that offer little assistance to clinicians in the provision of patient-centric care. 

Moreover, maintaining medical records that bring little clinical value not only wastes nurses’ 

time but also limits the time available to engage in value-added care activities. The cost 

implications alone justify a call-to-action to redesign documentation systems so that they are 

patient-centric and aligned with intended purposes. 

Studies That Focus on Improving Documentation 

Deficiencies in the nursing record, such as problems with accurately representing the patient, 

the time-consuming nature of recording, and the completeness of the record, have led to a series 

of interventions aimed at improving nursing documentation. The impetus for changing nursing 

documentation has come from several sources: hospital management, the nurses themselves, and 

nursing researchers. Compliance with legal mandates, paperwork reduction campaigns, and 

meeting professional standards are also common reasons for changing recordkeeping regimes. 

The changes made to the documentation process to reach these goals vary broadly. Much of 

this literature is characterized by contradictory case studies. Scharf43 reported a case study of one 

hospital that simplified a set of complex forms to enable nurses to spend more time caring for 

patients while still meeting the Joint Commission’s documentation requirements. Another case 

study44 involved a change from a preprinted form to a free-text, handwritten care plan for each 

patient. The studies reviewed include examples of those focused on understanding users’ needs 

(through assessing attitudes and opinions) and those focused on implementing and evaluating 

interventions designed to improve documentation. 

Dillon and colleagues45 conducted a survey to assess nurses’ readiness to adopt a new EHR. 

Their findings indicated that nurses had a positive overall attitude, although nurse age was a 

significant factor in determining nurses' attitudes regarding the EHR. Nurses were concerned, 

though, about the impact of the new EHR on quality health care delivery. In closing Dillon and 

coworkers noted that “these results clearly show that the nurses have real concerns about the new 

impending computer system and that the new system may be risky and might remove the human 

component of what they do”45 (p. 144). For example, a comment made by one nurse reflected the 

concerns of many, “I just don't want the system problems to interfere with patient care.” One of 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

her colleagues also commented, “I'm nervous about it [the impending system implementation]—

hoping that it will not slow down my productivity—or be too time-consuming”45 (p.144). 

Other studies have used educational interventions designed to improve documentation alone 

or documentation and care. Karkkainen and Eriksson46 completed a pre- and postintervention 

study, which involved an educational intervention to have nurses apply a theory of caring science 

to the care plans, to promote a more patient-focused documentation. Chart audit was done preand postintervention, and questionnaires assessed nurses’ attitudes about this theory-based 

recording method. The major change observed was more attention by nurses to patient views and 

increased recording of these in the plan.46 

Studies of computerized charting and care planning systems usually provide some measure 

for nurses’ satisfaction. Two surveys of nurses’ attitudes toward computerization are important 

to note. Axford and Carter’s47 study on how nurses believed computer technology impacted their 

practice is important in this regard. Their survey asked about resource consumption, nursing 

work practices, and professional and patient outcomes. Their findings indicated that nurses did 

not think technology would have a negative impact on practice. This was true for both those 

knowledgeable about computers and those less familiar with them— although the strength of this 

belief did vary, with experts feeling more strongly. 

Other researchers have examined the effects of computers on nursing documentation directly. 

Nahm and Poston48 did a quasi-experimental, modified time series study that measured the 

effects of the nursing module of a point-of-care clinical information system on nursing 

documentation and patient satisfaction. Data were collected before implementation, and after 

implementation at 6-, 12-, and 18-month intervals. Compliance with items applicable to nursing 

documentation in the JCAHO Closed Medical Review Tool was used to assess the quality of 

nursing documentation. Nahm and Poston found a statistically significant increase in the quality 

of nursing documentation after system implementation and a reduction in the variability of 

charting. Most importantly, charting compliance increased and continued at the 12- and 18-

month time points after initiation of the new system. This indicates that change is incremental, 

and that longitudinal studies are critical to assess the impact of computer systems. 

The body of the literature reviewed in this section provides evidence indicating that wellconstructed interventions, such as education and revising formats (automation and forms), can 

enhance documentation and improve patient care. The evidence also suggests that there is a timerelated pattern to user satisfaction, perceptions of value, and achievement of desired 

documentation outcomes following the implementation of new computer information systems. 

Nonetheless, the findings must be interpreted with caution due to wide variation of the settings 

examined, interventions applied, and methods of evaluation. As with all of the literature in this 

area, the main limitation is lack of generalizability, due primarily to the wide variation of 

documentation practices within and across organizations. 

Nurse Care Planning and Plans 

In health care organizations, the EHR, oral reports, handoffs, conferences, and health 

information technologies (HIT) are intended to facilitate information flow. In particular, the 

JCAHO specifically conceptualizes the care planning process as the structuring framework for 

coordinating communication that will result in safe and effective care.2 The Essentials of 

Baccalaureate Education for Professional Nursing Practice,

49 drafted by the accrediting body 

the American Association of Colleges of Nursing, lists several core competencies that directly 

relate to the nurse’s care planning process including the ability to “...diagnose, plan, deliver, and 

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Documentation and the Care Planning Process

evaluate quality care” (p. 11), “use appropriate technologies in the process of assessing and 

monitoring patients” (p. 14), “apply health care technologies to maximize optimal outcomes for 

patients” (p. 16), and “develop a comprehensive plan of care...” (p.16). Although there appears 

to be clear value to effective care planning and the process of communicating the plan, evidence 

of this in the literature lacks specificity. 

The patient care planning literature encompasses a wide variety of concepts, studies, and 

interventions. The main subdivisions of patient care planning in the literature are advance care 

planning (care at the end of life), case management (working with the entire medical team and 

associated professionals), and critical pathways or protocols for treating specific diseases. As 

defined, these categories are all potential conceptual matches and should encompass nurserelated care planning and plans. The majority of the care planning literature, however, is diseaseoriented or medically focused, with little attention to the actual judgments and actions nurses 

take in carrying out the interdisciplinary plan at the point of care. Nor does this literature 

evaluate the impact of nursing care on patient outcomes. We believe the following illustrates the 

content of literature related to nurse care planning and plans. 

Several studies have been done focusing on the introduction of the Scandinavian VIPS (well 

being, integrity, prevention, safety) model into care planning. Ehrenberg and Enfors34 performed 

a stratified, randomized controlled trial using chart audit and interviews. They reported that their 

study group that received a new form and educational intervention exhibited increased 

completeness and correctness of documented information, although there were still some areas in 

which the control group documented better than the study group. 

Care plan findings from Mason’s50 qualitative study indicated that care plans were not 

thought to adequately represent the patient, and consequently were not used in the planning or 

evaluation of care. Observations conducted as part of this study confirmed that the major guides 

to practice were report, direct observation of the patient, and bedside charts. In these clinical 

units, the care plan was viewed as actually discouraging thinking, because the standardized 

formats hindered individualized care by operating as check-off lists that discouraged nurses from 

engaging in mindful care planning. In one unit, however, the care plans were successfully 

integrated with practice.50 Nurses’ attitudes toward care plans in this unit were generally positive 

and the plans were used to aid in explanation and communication, and to guide practice. In this 

unit, care plans were kept at the bedside. The success of nurses’ adoption of the care plans was 

attributed to the fact that they were perceived as clinically driven, more representative of the 

patient’s condition, and there was a sense of local ownership. 

Smith and colleagues51 studied the implementation of a computerized care planning and 

documentation system, using the NIC and nursing outcomes classification (NOC) framework. 

Data were collected through questionnaires, observations, and chart audits both before and after 

computer implementation. Post implementation data revealed that the nurses’ attitudes toward 

computers were more negative and charting time was unchanged; however, chart audits revealed 

improvement in the completeness of the nursing record. 

In research where the intervention has focused on changing the care planning process, 

findings have shown that patient outcomes can be improved. Implementation of a care pathway 

for post surgical patients, to streamline nursing care of postoperative colon resection patients, 

resulted in a statistically significant shorter length of stay.52 In another controlled study, From 

and colleagues53 found that new care planning forms, as opposed to a narrative written in the 

medical record, could be associated with earlier recognition of patient problems, a shorter length 

of stay, and a higher accuracy in planning the discharge time. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Other studies have reported finding previously noted problems in the care planning practices. 

Research on the effects of the NANDA International, Nursing Interventions Classification (NIC), 

and Nursing Outcomes Classification (NOC) terminologies in the care planning process has also 

shown mixed results. Scherb53 found that nursing care did make a difference in patient outcomes. 

However, because the method of data capture, it was impossible to identify the nursing diagnoses 

and interventions that contributed to the positive patient outcomes.54

In a related study, Lillibridge55 found that when nurses were asked to list the type of data 

they would normally collect using specific examination techniques, 23 percent provided nursing 

assessment details. It can be argued that if nurses were provided with an explicit nursing 

framework (and language) to document and communicate about their care that nurses and the 

interdisciplinary team members would more readily understand the importance and impact of 

nursing care and patient outcomes. Others have also found that the care plans typically do not 

reflect actual nursing practice.56, 57

Even when care planning interventions are similar, as in the case of the introduction of the 

Scandinavian VIPS method for nursing documentation, results vary among studies. Studies by 

Darmer and colleagues58 show both more methodological rigor and more positive results. This 

controlled, longitudinal study introduced the VIPS care planning model to nurses on eight units 

(four study and control units, respectively). The intervention consisted of different educational 

interventions prior to utilizing the VIPS care planning model. Data included surveys of nurses’ 

attitudes towards documentation and their knowledge of the new regime. Nurses in the study 

group had more confidence in their ability to create good care plans and did better than the 

control group on the knowledge tests. Overall, the nurses in the study by Darmer and coworkers 

were more positively predisposed towards documentation than those in another VIPS study, by 

Björvell and colleagues.41 

The Björvell and colleagues41 study also featured a VIPS intervention and results overall 

were positive. There was a statistically significant score increase in quantity (P values for the 

quantity variables ranged from P < 0.0001 – 0.0003) as well as quality of the nursing 

documentation (P values of the quality variables ranged from P < 0.0001 – 0.0002). In a 

followup study, Darmer and colleagues59 reviewed 600 charts utilizing the VIPS model at four 

sites using a standardized audit tool. They found that nursing documentation significantly 

improved during the course of the study (P = .00001). After the second year, the participants 

used the keywords appropriately and correctly according to the VIPS model. Overall, this 

structured implementation program significantly improved nursing documentation. 

Implementing a new care planning system without sufficient cultural, educational, and 

organizational support has been identified as leading to problems. Educational interventions, in 

particular, are a major focus in the literature. Hansebo and colleagues60 found that although care 

planning documentation increased after an educational intervention, the level of assessment was 

low. The authors concluded that educational interventions were needed to improve clinical 

judgment. 

Lee61 also identified major educational issues associated with the implementation of 

computerized documentation systems. He argues that launching a care planning system alone, 

without knowledge of the diagnoses or how to use the care plans in clinical decisionmaking, 

limits their utility. For Lee and colleagues,30 the new system also increased nursing workload, 

primarily due to a lack of computers, and competition for terminals with other professionals and 

students. In the end, the nurses found the care plan lacking in three aspects: (1) content, primarily 

the inability to individualize patient care; (2) poor system function; and (3) lack of system 

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Documentation and the Care Planning Process

integration with the other information technology systems. In another article, Lee and Chang62

report on an interview-based evaluation of this system. In this latter study, the nurses interviewed 

saw the new system as paperwork and not patient-oriented. 

The quality of and implementation strategy for care planning systems has impeded adoption 

as much as the actual care plan within the system. Ammenwerth and colleagues63 found that 

planning and documentation of tasks (P = .004) and report writing (P = .019) required 

significantly more time with the computer based system than with the paper based system. For 

the care planning module, no statistically significant difference between the study and control 

groups was seen due to the limited number of items. At the conclusion of Ammenwerth and 

colleagues’ study, seven nurses (58 percent) agreed that the PIK software application saved time 

for care planning, but only three agreed that PIK saved time for documentation of tasks or for 

report writing. The majority of nurses agreed that with PIK, nursing documentation is more 

complete (10 nurses), legibility is better (9 nurses), and that the quality of documentation is 

better (8 nurses).63 However, Ammenwerth and colleagues did not tie these findings to patient 

outcomes or changes in nursing practice. The conclusion that the introduction of a care planning 

system alone, without supporting organizational change, will not work is also supported by 

Spranzo’s64 work. 

In summary, the nurse care planning literature indicates several things. First, when thought 

goes into the care planning process, better patient outcomes are possible. Second, altering the 

care planning process has thus far been done in an ad hoc manner and most of the evidence is 

from case studies. Individualized approaches have been implemented in specific settings. Their 

replicability across patient care settings, even from acute care to stepdown units within one 

hospital, has not been tested. While supporting the continuity of care on an individual unit is 

good, the larger issue of increasing continuity of care across time and space (across units and 

health care settings) needs to be addressed if patients are to receive truly holistic care. Third, 

current approaches to care planning have focused primarily on the care planning document itself. 

While some studies52, 53 have changed the care planning process, the focus has been the actual 

plan. Finally, when the care planning process has been computerized, there appear to be 

substantial system problems resulting from a lack of nursing input into the module’s design and 

functionality.30 Lack of nursing input has contributed to the failure of the nurses in these studies 

to embrace care planning and, at times, even to be able to judge whether a different care planning 

approach would result in better patient outcomes. 

Towards an Interdisciplinary Plan of Care 

Given the problems in developing a care planning system that works well for just nurses, it is 

clear why creating comprehensive systems that support interdisciplinary plans is that much more 

complicated. This is particularly true if Gage’s65 conception of interdisciplinary teams is utilized. 

He defines multidisciplinary teams as those in which consultation is a series of individual 

consultations, where interpretation is made independently by members of the medical team. On 

the other hand, interdisciplinary care planning occurs when the team collaboratively synthesizes 

the information and reaches consensus around treatment and goals for the patient. Much of the 

literature falls short of Gage’s ideal and what is categorized as interdisciplinary care planning 

should more appropriately be viewed as case management. 

The majority of articles on interdisciplinary care planning focus either on case management 

or clinical pathways. These emanate from specialties and areas that traditionally have had closer 

ties among a variety of professionals (doctors, nurses, social workers) to manage a patient’s 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

condition. Typical among the case management genre are case studies of interdisciplinary care 

planning in nursing homes66 or for the elderly.67 The clinical pathways articles focus on a 

specialty or specific unit, such as acute care.68 In one qualitative study of an interdisciplinary 

discharge planning process, Atwal69 found that many parts of the discharge process were 

regularly ignored and assessments were not done collaboratively. Nurses mentioned lack of time 

as the biggest barrier to interdisciplinary collaboration. Interdisciplinary care planning and the 

resulting plan can bring value to patients and enrich all disciplines; however, in its current 

iteration the vision proposed by Gage has not yet become a reality. 

Practice Implications 

Though the literature in this area lacks generalizability, there are a number of important 

implications that can be drawn. First, the enormous variability in the documentation and care 

planning practices exposed in this literature is a serious problem in and of itself. Given patients 

typically receive care from a variety of points across the health care system, moving from place 

to place where record content and format is variable, renders current medical records virtually 

useless in supporting patient-centric care in day-to-day practice. Moreover, information about a 

patient, once recorded, is either not accessible or—if available—is often in an unstandardized 

format (e.g., clinicians’ own words), resulting in countless errors of omission, misinterpretation, 

and redundancies in care. So too, most care planning methods are considered to bring little value 

and suffer from the same problems of poor design, poor accessibility, and no standardization. 

The lack of utility of the medical record in day-to-day practice begs the moral issue of whether 

the cost of maintaining the record in its current form (approximately 15 percent of a nurse’s 

time) is justified. The dollars spent on maintaining the “broken medical record” would bring 

more value if shifted to fund developing and refining industrywide solutions to repair the broken 

record. Further, the literature suggests that to compensate for poor record keeping systems, 

clinicians develop individualized shadow methods (scraps, also not standardized) to assist with 

organizing what each believes to be key information needed to carry out patient care. Since these 

information practices are nurse-centric and therefore variable, shadow methods further impede 

the flow and easy accessibility of patient information that promotes care continuity, quality, and 

safety. 

Finally, there are valid instances of successful education interventions that improve aspects 

of documentation and care. The examples, however, are all locally focused and consequently 

also do little to fix the broken medical record. We see the broken record as a serious and costly 

problem to the health care industry and one that deserves a patient-centric industrywide solution. 

There were no studies of industrywide solutions noted in the literature. Until there is a true 

commitment to developing and refining industry-wide solutions that ensure accurate and 

comprehensive documentation, facilitating patient-centric care, the improvements that are 

possible in the areas of safety, cost, quality, and continuity will not be fully realized. 

Research Implications

The research imperative for further study of this problem is manifested by the current state of 

the medical record and the high cost being incurred to maintain it. One approach to improve 

medical records is a patient-centric approach, which redesigns the recordkeeping system, and 

10 
Documentation and the Care Planning Process

that will automatically ensure that the continuity, quality, and safety of care are a primary focus. 

From this review, there are several key questions that need methodologically rigorous research: 

1. How does variability in documentation impact patient outcomes? 

2. What are the key components of an effective documentation process that is patient 

centered and improves the transfer of information among clinicians and across settings of 

care? 

3. What aspects of documentation are shared among an interdisciplinary team, and what 

contributions to the patient record can each team member effectively provide? 

4. Should documentation vary across settings of care? 

Conclusion 

The evidence reviewed in this chapter suggests that formal recordkeeping practices 

(documentation into the medical record) are failing to fulfill their primary purpose, of supporting 

information flow that ensures the continuity, quality and safety of care. Moreover, 

disproportionate attention to secondary purposes (e.g., accreditation and legal standards) has 

produced a medical record that is document centered rather than patient focused. Cumbersome 

and variable formats, useless content, poor accessibility, and shadow records are all evidence of 

the extraordinary failure of the medical record. Given the exorbitant cost of the record and urgent 

need for tools that facilitate the flow of patient-centric information within and across systems, it 

is imperative to develop broad-based solutions. 

Case Study: The HANDS Initiative and Plan-of-Care Method 

The HANDS method is an intervention currently being refined to bring a strong patient focus 

to the medical record by replacing current forms of care plans with a single, standardized plan 

and related plan of care processes. The method addresses the needs, uncovered in this chapter, 

for summary patient care information that is standardized, meaningful, accurate, and readily 

available to all clinicians involved in a patient’s care across time and space. The HANDS method 

embodies the concepts and characteristics of high reliability organizations and as such is fixated 

on ensuring the continuity, quality, and safety of patient care (See Figure 1: HANDS Method 

Framework). 

As depicted in the framework, the central thrust of the HANDS plan-of-care method is to 

facilitate clinician behaviors (mindfulness) and communication (heedful interrelating) that form 

the basis of a collective mind among the clinicians (interdisciplinary team) involved in a 

patient’s care. Organizations and systems factors must be aligned to support the mindfulness, 

heedful interrelating, and collective mind. The precursors to implementation of HANDS include 

culture readiness and a commitment to adopt and sustain the HANDS method (i.e., a 

commitment to change). Culture readiness is defined as an organization or system with an 

infrastructure that supports change and continuous learning, and is characterized by high levels 

of trust among its members and expectations that clinicians will engage in activities promoting 

mindfulness, heedful interrelating, and collective mind. Organization or system commitment to 

change is manifested by an organization or system formally adopting the HANDS standardized 

method for systemwide use, and by providing the necessary resources to educate, implement, and 

sustain the method across time. Finally, as is noted in the model, the patient care outcomes to be 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

achieved by using HANDS and enabling mindfulness, heedful interrelating, and collective mind 

are safety, continuity, quality, and evidence based. 

Earlier in this chapter, evidence from studies on nursing documentation and care plans as 

well as on interdisciplinary plans of care is presented and synthesized into a framework for the 

HANDS method. The method is an intervention that addresses the need for broadly based 

standardization of key aspects of documentation and communication, to facilitate patient-centric 

information flow. HANDS standardizes the plan-of-care documentation and processes, replacing 

the current widely variable forms, to support interdisciplinary decisionmaking that is based on 

shared knowledge among the clinicians. In this section, the history and future plans for the 

ongoing refinement of the HANDS method are presented.

This second part of the chapter focuses on the history of the HANDS Initiative and ongoing 

testing and refinement of the standardized plan-of-care method to date and future directions. The 

initiative addresses the gap previously identified in indicating the need for clinically relevant and 

patient-centric documentation and communication tools that support the collective mind (shared 

understanding) of the many clinicians involved in a patient’s care across time and space. The 

project formally began in 199870 with the main purpose of bringing visibility, utility, consistency, 

and accessibility to the nursing portion of the interdisciplinary plan. As was previously noted, 

nursing care plans generally have brought little value in day to day practice due to the wide range 

of formats, lack of individualization and accessibility, and the infeasibility of keeping them 

current. During the initiative’s early years the primary focus was on “perfecting” the format of 

the plan-of-care document through enabling technology and standardization. Through iterative 

refinement under real world conditions, we have learned that care plans, regardless of the quality 

of the document, bring little value unless they are an integral part of clinician-to-clinician (intraand interdisciplinary) communication, serving as the basis upon which a collective mind among 

clinicians about a patient’s care is formed. Our ultimate vision is to standardize the 

documentation and communication of a useful and dynamic interdisciplinary plan of care that is 

patient-centric, available, and used everywhere. In the following section, pertinent background 

information is presented, followed by a summary of the HANDS project accomplishments to 

date, future plans, and conclusions. 

History of HANDS 

The project began when our team of researchers attempted to use existing vendor software 

products to collect a nursing dataset coded with standardized terminologies, for a study of the 

Nursing Outcomes Classification in the mid-1990s.71,72 The terminologies had been developed 

for the main purposes of representing nursing in health care databases and generating 

comparable nursing data for evaluating nursing practice. At the time, however, it became very 

apparent that, because of the wide variation in the practices used by vendors to integrate the 

terminologies into their systems, data was not comparable and frequently not retrievable. The 

HANDS initiative was thus born to remedy this situation and a prototype automated plan-of-care 

system with a database architecture that supported the generation of comparable nursing data 

was developed. It was clear to us, then and now, that the use of standardized terminologies alone 

is insufficient to produce comparable data. Instead, comparable data is generated when the same 

types of information are gathered at the same time intervals, using the same standardized 

response sets (standardized terminologies), same database architecture, and the same rules of 

data entry. 

12 
Documentation and the Care Planning Process

Standardized Nursing Terminologies 

Since the late 1970s, efforts have been underway to identify nursing content and develop a 

means of representing it in computerized national health databases and clinical documentation 

systems. Werley and Zorn73 first described a minimum set of elements needed in Nursing 

Minimum Data Sets, and they noted that content (terminologies) would need to be developed to 

represent the nursing-specific items of diagnosis, intervention, and outcome. It was projected that 

collection of the elements represented by standardized terminologies would provide comparable 

data that allowed multiple uses (e.g., describe, evaluate, trend, and benchmark nursing 

practice).73 Subsequently, a number of terminologies have been developed to serve as response 

sets for nursing diagnosis, outcomes, and interventions. It is currently the purview of the 

American Nurses Association (ANA) Committee on Nursing Practice Information Infrastructure 

to set recognition criteria and formally recognize those terminologies meeting the established 

criteria. Over the years, the recognition criteria have been expanded and revised to align with the 

improvements in methods and tools for generating computable concept representations.74

Unfortunately the Committee’s actions have inadvertently confused the nursing constituency and 

thwarted progress toward achieving the vision of collecting comparable nursing data. 

Since the early 1990s, the Committee on Nursing Practice Information Infrastructure has 

recognized more than one terminology (response set) for each of the data elements (diagnosis, 

intervention, and outcome), thus causing potential adopters to ask the question, “How are we 

going to get standardized data if nurses use different standardized languages?” The more recent 

recognition of entities (e.g., Systematized Nomenclature of Medicine Clinical Terms [SNOMED 

CT], and ABC Codes) that encompass content from the originally recognized nursing 

terminologies (NANDA, NOC, NIC, Omaha System, Perioperative Nursing Data Set, Clinical 

Care Classification, International Classification on Nursing Practice) has begged the question of 

how we are to use these recognized entities to achieve our professional goal of generating 

comparable nursing data. In truth, it is not clear how the 12 ANA recognized terminology 

entities can be used to generate comparable nursing data.75

The Terminology Solution in HANDS 

From the beginning the HANDS project team grappled with how to create a long-term 

strategy that would generate professionwide, comparable nursing data when there was no 

professionwide commitment to a single terminology system. Given the circumstances of the 

time, we realized that professional consensus around a single terminology system was unlikely to 

occur in the absence of real time testing that demonstrated the value. We thus selected the 

terminology system with the broadest applicability—and that possessed characteristics indicative 

of its potential to grow and evolve over the long term—to be included in the HANDS method. 

The terminology system includes what is now called NANDA Classification,76 NIC,77 and 

NOC78 to represent the diagnosis, intervention, and outcome data elements respectively gathered 

in HANDS. All three of the terminologies have infrastructures in place to maintain and evolve 

the terminologies across time. The NANDA, NOC, and NIC (N3) terminologies provide 

comprehensiveness of terms, in that each includes terms to describe care in all types of settings. 

Additionally, all have been developed through research involving literature review and the 

extensive input of large numbers of nurses. 

The rate of diffusion of a new language can be accelerated by defining a clear direction and 

taking action. For example, usage of N3 in the 43 nursing programs in Michigan substantially 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

increased from1997 to 2001 following a resolution by Michigan Nurses Association to support 

N3 use in the State. NANDA usage remained high in 2001, with 92 percent of the schools of 

nursing (community college and university programs) indicating use. NIC usage rose from 22 

percent to 58 percent and NOC usage rose from 0 percent to 58 percent between 1997 and 

2001.79 

Finally, there are several other points of evidence worth mentioning that indicate the longterm viability of the N3 terminologies within the nursing community at large. First, the N3 

terminologies form a subset of SNOMED CT, the comprehensive clinical terminology. The 

SNOMED CT terminology is recognized by the National Centers for Vital and Health Statistics 

and the Consolidated Health Informatics Initiative as an acceptable standard for the Federal 

Patient Medical Record Information effort80 and is an ANA recognized terminology.75 Though 

nursing-specific terminology content is available in SNOMED CT, it is not the purview of 

SNOMED CT to keep the content current. Rather, the responsibility falls to nursing entities 

(terminology developers) to ensure that the quality and comprehensiveness of the terminologies 

is sustained and improved across time. 

The N3 terminology developers are already taking responsibility for ensuring that the content 

is updated regularly, and that the terminology structures evolve in alignment with accepted 

standards for computable concept representations. As was previously noted, all three have strong 

internal structures for maintenance and updating of these terminologies, which have been in 

place for over a decade. The ongoing maintenance and support for NIC and NOC are provided 

through the University of Iowa-based Center for Nursing Classification and Clinical 

Effectiveness. To date, NIC has been translated into eight foreign languages and NOC into 

seven, indicating a growing international acceptance of these terminologies.81 The ongoing 

maintenance and development of NANDA are provided by the NANDA International office at 

info@nanda.org. Every 2 years a joint N3 international conference is held at a central location in 

the United States to promote crosspollination of ideas that support continuous diffusion of these 

terminologies both nationally and internationally. 

Another indicator of the long term viability of N3 is its growing and extensive presence in 

the literature. The technique for measuring such presence, bibliometrics, has been used in health 

care to evaluate the extent and rate of diffusion of an innovation.82 For purposes of this chapter, a 

systematic search was conducted (with the help of CINAHL® personnel) to identify numbers of 

journal articles, complete books, and proceedings in which some aspect of the ANA-recognized, 

“nursing developed” terminologies (nursing content only) were a “major focus” between 1996 

and 2006. The results appear in Table 3, and are organized by the nursing terminology system 

defined as providing terms for the data elements of nursing diagnosis, intervention, and outcome. 

Using this definition, there are five currently recognized ANA nursing terminology systems in 

addition to N3: the International Classification on Nursing Practice, the Omaha System, the 

Perioperative Nursing Data Set, the Clinical Care Classification, and (formerly) the Home Health 

Care Classification. Though the results must be interpreted with caution, it is readily apparent 

that there are major and substantial differences in the number of literature entries and trends 

between the N3 system and the others. Moreover, the number of entries for N3 appears to be 

growing rather than diminishing. Further analysis and interpretation of the findings will be 

presented in a forthcoming manuscript. Also of note is that the HANDS research conducted to 

date is providing evidence that N3 can be successfully integrated into a standardized, technologysupported care planning method, and generate comparable data to evaluate nursing practice. 

14 
Documentation and the Care Planning Process

The HANDS Initiative: Phase 1 

Phase 1 of the HANDS project emerged in response to the absence of a path that would lead 

to the collection and generation of comparable nursing data. In this phase, our team focused on 

creating a standardized prototype of a dynamic, technology-supported plan that would generate 

comparable data. Our vision, then and now, is to evolve a useful care planning method that 

standardizes both the plan and the planning processes, is used widely, and generates standardized 

and comparable data for identifying and disseminating best practices. For a more specific 

account of the prototype development, see Keenan and colleagues70

In creating the original HANDS prototype, the team made a deliberate choice to incorporate 

the N3 terminology system to represent the data elements of clinical (nursing relevant) diagnosis, 

interventions, and outcomes for the reason described above. The initial HANDS work thus 

focused on perfecting a tool that could be used to document the plan and generate comparable 

data. The teams’ efforts focused on the plan format, database, and rules of data entry. The 

approach matched the assumed need for such a tool with the availability of the means, including 

the technology and terminologies.83 It was believed that the tool would help meet the vision of 

the HANDS. 

Version 1 of HANDS (single user application) was initially implemented and tested in one 

intensive care unit. A sociocultural approach, putting our users front and center, was used to gain 

an understanding of the impact of the HANDS technology on nurses’ work practices.84 Many 

qualitative and simple quantitative methods were employed and repeated across time in our 

evaluations, and the results were added to improve the HANDS tool and processes through 

iterations of the design, test, and refine cycle. Our methods included observations, surveys, focus 

groups, “think-alouds,” analysis of individual use patterns available in transaction logs, and 

routine checks of term meaning reliabilities and NOC outcome ratings. 

The findings85 gathered from the multiple methods in the pilot study helped uncover a 

number of issues with the technology that were not always apparent to our nurse subjects and 

permitted us to implement remedies. Most importantly we learned that our initial approach was 

document-centric. And although our method improved compliance and satisfaction with the care 

planning documentation, it did little to promote the collective mind of the clinicians involved in 

care. In fact, we found that many of the individual nurses religiously and mindfully updated 

plans of care in isolation. Rarely did nurses use the plans to guide clinician-to-clinician transfer 

of information. In retrospect, this finding was understandable and echoed the evidence reviewed 

in this chapter, that the plans have typically brought little value in day-to-day practice. Expecting 

nurses to use plans in more patient-centric, rather than document-centric, ways without educating 

them about how this might be done is unlikely to bring about the desired change. These results 

were used to refine the software and revise the rules and training for Phase 2 of the HANDS 

research initiative. 

The HANDS Initiative: Phase 2 

In preparation for this phase, the HANDS tool was converted to a Web-based application. 

WEBHANDS allows the clinician to easily enter and update a patient’s plan from any terminal 

on the unit. Since the plan-of-care histories are stored on a central server, clinicians involved in a 

patient’s care also have ready access to the history of the patient’s plan from previous episodes. 

This information provides the clinician an “at-a-glance summary” of the issues that have been 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

addressed through the care provided by the health care team, and progress toward outcomes 

across time. The improvements in the software accessibility were expected to streamline the 

documentation of the plan of care and make it easier to integrate the plan into handover 

communication (intradisciplinary heedful interrelating) 

Phase 2 research built on lessons learned in Phase 1, as well as the integration of evidence on 

communication, handovers, and behaviors characteristic of high reliability organizations. There 

are two major aims of this 3-year, multisite study of the HANDS method, HIT Support for Safe 

Nursing Care, funded by the Agency for Healthcare Research and Quality.86 The aims include 

demonstrating that standardization of the HANDS method can be maintained across multiple 

diverse sites and that that the method fosters mindfulness, heedful interrelating, and collective 

mind as described in our framework presented earlier in the chapter. As can be seen, our 

emphasis moved from a document-centered to a patient-focused plan-of-care method that 

encompasses both the plan and the planning processes. 

In the study, the HANDS method is implemented and fully evaluated on the participating 

units. Nurse champions are first identified and educated (40 hours: combination of in class, and 

independent study). The champions, in turn educate the remaining nurses employed on the unit 

(6 hours: 2 hours of classroom, 4 hours of independent study). A greater emphasis was placed on 

educating nurses to engage in heedful interrelating during handovers in this phase of our 

research. At this writing, we have just entered year 3 of the study and all units are fully live with 

the HANDS plan-of-care method. Nurses are required to enter admission or update care plans on 

all patients and to use the plans to structure communication at every handover. 

Similar to our pilot phase, we are using multiple and repeated methods of evaluation and 

have already analyzed and integrated early findings into the tool and method.87, 88 Thus far, we 

have demonstrated that standardization of care plan entry, storage, and retrieval can be 

maintained across the eight participating diverse units with the HANDS software tool. As in the 

pilot unit, nurses have reported high levels of satisfaction with the tool and are nearly 100 

percent compliant in entering admission and update plans on all patients at every handover. Still 

needing improvement is the use of the plan at handovers (heedful interrelating). From interviews 

with nurses from our four first-year study units, we learned that there was wide variation in how 

nurses used the plans in the handover, and this was thought to add little value.88 So, too, nurses 

complained that the most current plan was not always readily accessible for the handover. To 

remedy the situation, the nurses recommended developing a consistent format for handovers and 

creating easy access to the most current plan via the computer. The feedback was used to 

improve the software and plans of care were made readily available to the nurse via the patient 

list screen. In addition the SHARE (S-ketch, H-ANDS, A-ims, R-ationale, and E-xchange) 

structure was devised to help nurses uniformly integrate the plan of care into the handover 

process and both were added to the training of nurses in our year-2 study units.88 

At this writing the four year-2 sites have been live with the revised HANDS method for 

nearly 4 months and, as with the year-1 sites, indicate satisfaction with the tool and almost 100 

percent compliance with entering plans as directed. Nonetheless, even with the new 

enhancements, issues are surfacing that indicate that the revamped handover process is not yet 

fully working as expected. Further study of this issue is planned to determine how the handover 

communication can be improved. Intervention will then be devised and tested in an effort to 

improve heedful interrelating through our continuous learning model. In addition, we will 

complete our planned data collection, which will allow us to more thoroughly evaluate 

mindfulness and the impact of the HANDS method on the safety culture and error rates. 

16 
Documentation and the Care Planning Process

Future Plans for HANDS

Even without completing the full evaluation of the HANDS method in the current study, 

findings to date suggest several next steps. First and foremost, the study has provided evidence 

that the HANDS method is valuable and stable and should be considered for fuller adoption. This 

is because most of the benefits of the method can only be realized through widespread adoption 

and use, which motivates commitment that cannot be achieved when only one or two units in a 

system have adopted the method. For example, plan-of-care histories are not readily available 

unless all units in the system are using HANDS. Nurses also are reluctant to change comfortable 

(though variable) handover routines to embrace standardization before there is a full 

organizational commitment to the standardization. So, too, without widespread adoption and use 

of the method, it is difficult to identify best practices and disseminate these to the practitioners at 

the point of care through HANDS infrastructure. As is noted in our framework, depicted in 

Figure 1, the level of success of HANDS is integrally connected to the level of commitment to 

the change by the overall organization. For this reason we are encouraging organizations who 

express interest and readiness to adopt HANDS, to commit to full organization and adoption of 

the HANDS method. 

We also see the need to formally position the HANDS method as an interdisciplinary 

initiative. As was noted in the previous sections’ conclusions, there is a pressing need for tools 

that support the collective mind of the entire interdisciplinary team around a patient’s care. The 

HANDS method already includes a number of features that can be easily adapted to 

accommodate the needs of the interdisciplinary team members. At this time a future study is 

planned to collaborate with physicians on refining the method for interdisciplinary use. 

Finally, the method has been designed to work in and across all types of settings where 

patients seek care. To bring the intended value the method must work regardless of the Clinical 

Information System (CIS) adopted within the institution. We have begun planning the 

development of a universal connector that will allow HANDS to seamlessly connect to an 

organization’s CIS regardless of the vendor types. In addition, other studies are underway to 

determine how to make HANDS available for immediate and widespread use. Of deepest 

concern and the direction of the team’s passion and efforts is achieving our longstanding vision 

for health care. 

Even without completing the full evaluation of the HANDS method in the current study, 

findings to date suggest several next steps. First and foremost, the current study has provided 

some evidence that the HANDS method is valuable and stable and should be considered for wide 

scale adoption. This is because most of the benefits of the method can only be realized through 

wide scale adoption and use that motivates commitment that cannot be achieved when only one 

or two units in a system have adopted the method. For example, plan of care histories are not 

readily available unless all units in the system are using HANDS. Nurses also are reluctant to 

change comfortable (though variable) handover routines to embrace standardization before full 

organization commitment to the standardization has been established. So too, without 

widespread adoption and use of the method it is difficult to identify best practices and 

disseminate these to the practitioners at the point of care through HANDS infrastructure. As is 

noted in our framework, depicted in Figure 1, the level of success of HANDS is integrally 

connected to the level of commitment to the change by the overall organization. For this reason 

we are encouraging organizations who express interest and readiness to adopt HANDS, to 

commit to full organizational adoption of the HANDS method. 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

It could be important to formally position the HANDS method as an interdisciplinary 

initiative. As was noted in the previous section, there is a pressing need for tools that support the 

collective mind of the entire interdisciplinary team around a patient’s care. The HANDS method 

already includes a number of features that can be easily adapted to accommodate the needs of the 

interdisciplinary team members. Finally, the method has been designed to work in and across all 

types of settings where patients seek care. As such, to realize the intended value, the method 

would need to be effectively integrated in all clinical information systems across institutions. 

Search Strategy 

The areas covered in this literature review were nursing documentation and care planning. 

The literature cited in this chapter was identified in several ways. The medical and nursing 

literature on care planning, standardized terminologies, documentation, and quality indicators 

has been reviewed, selecting and retaining only those references that pertain to this work in some 

way regardless of the quality of the evidence. Additionally, a comprehensive search of the health 

care and organizational behavior literature was conducted, from 1996 to 2006 in MEDLINE®

(using the OVID interface), CINAHL®, Cochrane Library, PubMed®, Dissertation Abstracts 

International, and Business Source Complete (EBSCO) to find high quality evidence available 

on nurse care planning and documentation. The main MeSH® subject search terms included 

continuity of patient care, documentation, medical errors, nursing records, patient care planning, 

and quality indicators–health care. A successive fractions search strategy was employed—a large 

selection of articles was made and then this was pared down to create a subset of the most 

applicable articles. To generate a large collection of potentially appropriate articles, each subject 

term was searched with minimal parameters from the subject heading; generally methods, 

standards, trends, and utilization were selected generating 9,422 matches. The additional limits 

of clinical, controlled, and randomized controlled trials (English) were set, producing a total of 

118 matches. 

Review of the 118 studies revealed that a number were not pertinent. For example, none of 

the 22 patient care planning articles pertained to nurse care planning. Only 3 of the 31 

documentation articles were relevant. Many of those in the overall category of documentation 

were general and did not pertain to nursing. Also documentation often referred to research data 

collection or some other intervention, and not to patient care documentation. Consequently the 

results of the three searches (patient care planning AND nursing records, patient care planning 

AND documentation, and nursing records AND documentation) were reviewed to identify other 

pertinent studies, largely evaluative in nature. In these secondary searches, articles by 

anonymous authors, foreign language materials, commentaries, letters, 1-2 page articles, and 

those that were out of scope were eliminated. The resulting summaries of these articles appear in 

two evidence-based tables. Table 1 includes 17 studies representing the literature associated with 

recordkeeping quality, including studies evaluating completeness, accuracy, and timeframe of 

documentation. In Table 2, 22 articles are included describing research aimed at improving 

documentation and care planning practices. 

18 
Documentation and the Care Planning Process

Author Affiliations 

Gail M. Keenan, Ph.D., R.N., Associate Professor, School of Information, University of 

Illinois at Chicago. E-mail: gmkeenan@uic.edu. 

Elizabeth Yakel, Ph.D., Associate Professor, University of Michigan. E-mail: 

yakel@umich.edu. 

Dana Tschannen, Ph.D., R.N., Clinical Assistant Professor of Nursing, School of Nursing, 

University of Michigan. E-mail: djvs@umich.edu. 

Mary Mandeville, M.B.A., Project Director, Department of Public Health, Mental Health, 

and Administrative Nursing, University of Illinois at Chicago. E-mail: mandevil@uic.edu. 

Acknowledgment 

We wish to acknowledge the AHRQ funding support for the 3 year study entitled HIT 

Support for Safe Nursing Care, 7-R01 HS01 5054-02. 

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22 
Table 1. References Associated with Recordkeeping Quality (Completeness, Time) 

Source Issue Design Sample Methods/Measures Selected Findings Allen 199829 Examines 

nurses’ views of the nursing record and its usage in practice 

Qualitative study, United Kingdom 

1 Hospital 2 Units 29 Registered nurses 8 Doctors 5 Auxiliaries 11 Clinical managers 

Observations Interviews 

-Written form of the nursing main components: (1) pro foinformation is recorded; (2) a (patient’s problems are identnursing response is agreed ukardex (record of patient’s p-Perceptions of care planninincluded ‘problems’ to satisfy initiatives; (2) completed for senior staff; (3) mechanistic concerns; (4) devalued, as it patient’s discharge; (5) rarely stay. 

Bjorvell 200241 Evaluate 

effects of intervention on the quantity and quality of nursing documentation 

Quasiexperimental longitudinal study 

1 Hospital 3 Wards 269 Patients records 

Intervention = organizational changes and education regarding nursing documentation, with the VIPS model using the Chart Audits (Cat-ch-Ing Instrument) 

-Statistically significant score values for the quantity variab0.0001 – 0.0003) as well as documentation (

P values of t

ranged from 

P < 0.0001 – 0.

wards, directly after the inter

Currell 200325 Assess the 

effects of registered nurses’ record systems on nursing practice & patient outcomes 

Cochrane systematic review 

8 Clinical Trials  1,497 people 

Systematic Review -No conclusive evidence was 

practice attributable to chang-RNs experience tensions behospital management docum

Ehrenberg 200134 Analyzes the concordance 

between nursing documentation & descriptions of practice 

Case comparison study random sampling 

17 Nursing homes wards  85 Patients 128 interviews 

Audits of records; Interviews of patients and RN 

-Problems more frequently rethe patient records—betweepatients’ problems identified recorded. -Concordance between nursrecorded data was significangroups on mental condition (

< .005) 

23
24

Source Issue Design Sample Methods/Measures Selected Findings Griffiths 199942 Determine adequacy of nursing documentation in describing patient care Retrospective, criteria based audit Random sampling 1 Trust 103 care plans Audit of Charts -Room for improvement in th

evaluation within the nursing 

Hardey 200031 Explore the role of RN interaction and documentation on patient care Qualitative, nonexperi- mental ethnographic study 1 Hospital 5 Wards 34 Registered nurses 23 Handovers Observations Interviews -Nurses argued repeatedly t

notes) were more up to datewere a better source of inforconventional paperwork. -Care plans were not used to 

Karkkainen 200527 Synthesis of literature surrounding patient care & nursing documentation Meta-synthesis evaluation study 14 Qualitative research reports Literature Review and Synthesis (1996 – 2003) -Individualized care not clea

documentation; tasks descripatients’ experiences of thei-Documentation did not refleto the patient. The structure which is presupposed by the individual recording of patien

Korst 200313 Determine time spent on documentation Work sampling study 1 Hospital 1 Unit 120 Observations Observations (of documentation in the EHR and paper format) -Percentage of time spent by 

15.79% spent on all documeused 10.55% of nursing time5.24% of time; 11.39% of timcompared with 4.4% at othe

Langowski 200526 Determine electronic documentation systems link with improved quality Literature review 5 Studies Literature Review -Overall, online nursing docu

be beneficial in improving dorequirements, end-user satisnursing is practiced 

Larrabee 200140 Evaluates 

differences in documentation after implementation of nursing information system 

Time series evaluation study 

1 Hospital 3 Units 

Intervention = implementation of care planning feature in a NIS (Nursing Information System) 

-Mean nurse assessments o(NASSESS) scores were stap<0.000 among nurses durin

time points. No consistent pathe highest/lowest score, althlowest score at Times 1 and -Six months of using a nursinnot sufficient time for registedocumentation mastery (as escores from Time 1 to 2 and for many of the variables). 
25

Source Issue Design Sample Methods/Measures Selected Findings Ngin 199332 Explores user 

acceptance of health information technology 

Nonexperimental, descriptive study 

547 Registered nurses 

Focus Groups Observations Surveys 

-Health information technolocoordination so that informatRegistered nurse tasks are cmanner. -Hospital membership, positnorms significant predictors -Organizational variables weactual computer use, and indbetter predictors of attitudina

Poissant 200514 Identify factors 

associated with differences in effectiveness among electronic health records 

Systematic review 

23 Studies Literature Review -Use of bedside terminal and 

respectively saved registered of time spent documenting d-Desktop for computerized pfound to be inefficient, increa328% (Medical doctor time p

Sterling 199638 Determine 

change in documentation of wound assessment 

Nonexperimental, comparative independent groups study 

2 Hospitals 3 Wards 46 Patient charts 

Chart Audits -Relevant parameters of wou

documented more frequently assessment chart was used -Many of the delaying factors in the literature for wound ca

Stokke 199936 Evaluate 

quality and completeness of documentation 

Nonexperimental, descriptive study 

2 Hospitals 5 Wards 55 Patient Records 

Chart Audits -Nursing care plan was pres

Nursing goals were lacking idiagnosis and planned interv18%, and 45% of the diagnoconcerning patient progress -The nursing care plans were the records and discharge no(NBH recommendations not 

Taylor 200237 Identify 

problemsolving studies used while providing patient. care 

Qualitative, nonexperimental study 

1 Hospital 33 Registered nurse students/Registered nurses 

Observations Interviews 

-Nurses accessed four main preparing to carry out a procpatient documentation, previpatient, and a selection of ot“miscellaneous.” -Patient documentation (histmost significant sets of docunursing care plans reviewed convey the specific informatithe required procedures; 1/3 written documentation, but dpreference for source. 
26

Source Issue Design Sample Methods/Measures Selected Findings Tornkvist 200339 Determine effects of an implementation of pain- advisers on satisfaction & documentation Controlled clinical trial 5PHCCs 53 Registered nurses Intervention = implementation of ‘pain advisers’ Survey -Several statistically significa

achieved after the introductiostudy units -Increased registered nurse documentation in study units Tornvall 200433 Determine what docu- mented in the health record Nonexper- imental, descriptive study; stratified random selection 27 Primary health care centers 154 District nurses 41 Nursing records Survey Chart Audit (using Cat- ch-Ing,) -Keywords “nursing interven

and “nursing status” received whereas keywords “nursing diagnosis” received the lowe-Patient status found in 30% keyword “nursing interventiomedical details and medicall-Predominance of documentstatus rather than nursing sta

Urquhart 200524 Update of Currell and Urquhart (2003) Cochrane Review assessing the effects of registered nurse record systems on nursing practice & 

Patients outcomes 

Systematic review 

26 Qualitative studies 

Systematic Review Qualitative research on nurs

documentation of verbal excnursing care, and organizatinconclusive concerning how represent nursing practice aor computerized) improve pa
Table 2. References associated with Improving Documentation and Care Planning Practices 

Source Issue Design Sample Methods/Measures Selected Findings Ammenwerth 200163 Investigate influence of 

information technology on time and quality of documentation 

Randomized control trial 

1 Hospital 5 Medical doctors 12 Registered nurses 60 Patients 

Intervention = implementation of a nursing information system. Documentation Analysis; Survey 

-Documentation of tasks (P = .019) required more time wversus the paper system; timwas not significantly differen-Survey—7 registered nursesaved time for care planningPIK saved time for documenwriting; 10 registered nurses documentation was more cothat legibility was better & 8 of documentation was better

Atwal 200269 Understanding 

of RNs’ perception of the discharge process 

Case study 1 Trust 

19 RNs 

Interviews Observations 

-Communication dependent between members of the teacommunicating with others oconsuming task) -RNs concerned that nurses they did not comprehend at the key area where informatmiscommunicated. 

Axford 199647 Determine 

impact of CIS on nursing practice 

Nonexperimental, descriptive study 

33 Registered nurses (interviews) 291 Registered nurses (survey) 

Interviews Surveys 

-Nurses (whether computer do not expect the technology on practice. -The two groups differed mobeliefs. One startling outcomresponse time delayed carecomputer-user group and diresult. 

Bjorvell 200241 Evaluate 

effects of intervention on the quantity and quality of nursing documentation 

Quasiexperimental longitudinal study 

1 Hospital 3 Wards 269 Patient records 

Intervention = organizational changes and education regarding nursing documentation with the VIPS model Chart Audits (Cat-ch-Ing Instrument) 

-Statistically significant score values for the quantity variab0.0001 – 0.0003) as well as documentation (

P values of 

ranged from 

P < 0.0001 – 0.

wards, directly after the inter

27
28

Source Issue Design Sample Methods/Measures Selected Findings Darmer 200659 Evaluate the quality of nursing assessment and quantity of care plans using the VIPS model Evaluation study 4 sites 600 Patient charts Intervention = implementation program introducing the VIPS model Chart Audits (Cat-ch-Ing Instrument) -Nursing documentation sign

the course of the study (P = -The structured implementatimproved nursing documenttraining of the entire nursing 

Darmer 200458 Explores registered nurses’ knowledge and attitudes towards documentation Controlled clinical trial 1 Hospital Intervention = implementation program introducing the VIPS Model Survey & Test -Experimental group were si

convictions that they had the plans (

P = 0.03) and that the

= 0.01). -Experimental group showed control group, although both the knowledge tests 

Dillon 200545 Predict 

registered nurses intention to adopt Electronic Health Records 

Nonexperimental, descriptive study 

1 Hospital 140 Registered nurses 

Survey -Age was a significant factor 

attitudes towards the electro(P < .05). -Age had a direct (P = .02) a

.02) effect on nursing attitudpatient record system. -Image had a direct effect (

P 

nurses towards the electroni-Nurses presented concern patient record system, thinkiremove the human compone

Ehrenberg 200134 Analyzes the concordance 

between nursing documentation & descriptions of practice 

Case comparison study, random sampling 

17 Nursing homes wards  85 Patients 128 Interviews 

Audits of records Interviews of patients and registered nurses 

-Problems more frequently rthe patient records—betweeproblems identified by the nu-Concordance between nursrecorded data was significangroup on mental condition (

P 

.005) 
29

Source Issue Design Sample Methods/Measures Selected Findings From 200353 Evaluates care 

planning in 2 different ways, and its effectiveness on improving outcome 

Randomized controlled prospective 

Study 1 (S1): 1 Hospital 4 Units 222 Patients Study 2 (S2): 1 Hospital 4 Units 304 Patients 

S1 Intervention = Registered nurses & Medical doctors collaboratively developed care plans S2 Intervention = care plan randomly removed from record Interview Chart Audits 

(S1) -Problems identified earlier wvs. 3 days) - Solutions initiated earlier wstatistically significant); LOS groups (Not statistically sign (S2) -Patients with planning form length of stay (P = .02) and expected length of stay (P = -Accomplishment of plan of unchanged. 

Hansebo 199960 Comparison of 

nursing documentation before and after a supervised intervention 

Pre-/postintervention study Sweden 

3 Wards 58 Patients 

Intervention = implementation of individualized and documented care using the RAI/MDS Chart Review 

-Daily notes increased both intervention) and within parts (patient situations increased 61%, and evaluations by 100-52% of the Resident Assesdocumented in care plans. 

Karkkanien 200546

Extent to which theorybased documentation reveals actual patient’s experience with care 

Pre-/postintervention study 

6 Hospitals 7 Wards 137 Registered nurses 

Intervention = educational component to apply theory of caring science to care plans Audits Surveys 

-Post-intervention, more atteviews and increase in record-RNs need strong support frsuccessfully implement a thesystem 

Lee 200530 Identify factors 

influencing effectiveness of information technology 

Crosssectional, nonexperimental study 

120 Units 738 Surveys 

Surveys -Major issues identified by u

documentation systems: harcontent design, poor system requirement, privacy/legal viperspectives -Nurses were dissatisfied wiinability to individualize, poosystem integration 
30

Source Issue Design Sample Methods/Measures Selected Findings Lee 200561 Explore factors affecting nurses’ use of nursing diagnoses in charting standardized nursing care plans Qualitative Taiwan 1 Hospital 12 Registered nurses Interviews -Themes described by nurse

diagnoses in standardized nchoosing familiar patient proto existing paper form; (2) Infactors—turn to SOAP notes the standardized forms were Unavailable subjective data—data; (4) Unrealistic expecte(expected goals largely ignointervention—selected or ad(listed activities comprehensrequirement for consistent emeaningless tasks (most labdocumentation). Lee 200462 Explore nurses’ experiences using a standardized care plan Qualitative Taiwan 1 Hospital 19 Registered nurses Interviews -Themes describing impact o(1) being reminded of care pin making care plans (with sMaking shift reports very timUndesirable content design to individual patients); (5) papatient-centered (time consu-Some patient problems ignopaperwork load Lillibridge 199955 Investigate health assessment and documentation practices Nonexperi- mental, descriptive study 1 Hospital 2 Domiciles 65 Registered nurses Survey -Only 23% of nurses mentio

details when asked to list the collect for specific examinati- Findings generally indicatemaintain a medical- versus-nactions—perpetuates view thmedically driven 

Mason 199950 Investigate 

current care planning and effects on practice 

Qualitative United Kingdom 

5 Trusts 5 Units 

Observations Focus groups Subject Diaries 

-In the 4 comparable units, tidentified with care planning pressure, not seen as valuab-Observation confirmed the were verbal report, direct oband bedside charts. -In the specialty unit, the carwell with practice, were viewcommunication & practice, a
31

Source Issue Design Sample Methods/Measures Selected Findings Nahm 200348 Determine 

effects of a clinical information system on documentation & patient satisfaction 

Quasiexperimental study 

1 Hospital 11 Units 288 Patient charts 

Chart Audits Survey 

-13% increase in compliance (85% vs. 98% at 18 months) intervention of a clinical info-After intervention, each of thshowed a statistically significquality of documentation (

P 

Scharf 199743 Examine the 

association between time associated with documentation practices and patient outcomes 

Pre- and postcontrolled pilot study 

2 Units 100 Patients 

Intervention = revised flow sheets replaced previous documents. Included standard nursing interventions for the most commonly identified nursing diagnoses. 

-A decrease of 20 minutes in minutes vs. 123 minutes) aftpatient outcomes (length of medication errors, and falls) both units. -Slight improvement in patieknowledge rates on the expedecreases in satisfaction ancomparison unit. 

Scherb 200254 Identify effects 

of nursing interventions noted in the EHR on patient outcomes 

Longitudinal study 

2 Facilities 669 Patients 

Chart Review (care plan and NOC outcomes on admission and discharge) 

-Nursing care did make a difoutcomes, although it was nwhich interventions contributoutcomes -3 outcomes with the largest patient population were signdischarge compared to the a.008). 

Smith 200551 Identify 

association between a computerized documentation system with satisfaction, completeness, and timeliness 

Quasiexperimental, evaluation study 

3 Units 46 Registered nurses 141 Patient Records 

Intervention = implementation of electronic care planning system Survey Observations Audits 

-Statistically significant decreto post-intervention: (1) comnurses ’ jobs easier (

P < .00

steps and allow registered nefficient (

P = .002); (3) incre

allow RNs more time for pat(4) computer increases costregistered nurses’ workload -Completeness of document(34%) documentation elemewere significantly more com49 (60%) of the data elemenand five data elements (5%) intervention. -Time spent with the patient to postintervention (40.4 minstatistically significant) althoremained unchanged 
32

Source Issue Design Sample Methods/Measures Selected Findings Spranzo 199364 Effects of computerized care planning on select outcomes Pre-/post- intervention study with qualitative component 1 Hospital 4 Units 88 RNs 153 Patients Intervention = implementation of a computerized care planning system Survey & Patient interviews -Introduction of care plans h

outcomes. -Quality of nursing care remdifference in documented ca

Stephen 200352 Identify link between implementa- tion of critical path and patients length of stay Pre-/post- intervention Study 1 Hospital 138 Patients Intervention = implementation of the critical pathway for Patients undergoing colon resections -Mean total length of stay wa

pathway patients compared patients (P < .001) -Average cost per patient, wadded, was higher in the preto post-pathway group (P = 

Table 3. Number of CINAHL “Major Focus” Entries for the 5 ANA Recognized Nursing Interface Terminology SysteTerminology systems** 1996-2000 2001-2005 2006 – 10/27/06 Total NANDA 115 189 45 349 NIC 38 126 23 187 NOC 26 114 25 165 Total/***duplicates 179/19 429/145 93/26 701/190 1. N3 Total minus duplicates 160 284 67 511 2. ICNP 5 44 4 53 3. OMAHA 25 19 3 47 4. PNDS 5 8 1 14 5. CCC**** 2 6 - 8 * Includes journal articles, books, and conference proceedings in which a terminology system or component of it was considered a “m** Includes terms for nursing diagnoses, interventions, and outcomes. NANDA diagnosis, NIC interventions, and NOC outcomes, thou

by ANA as interface terminologies, are used in combination (N3) as a terminology system. Thus there are currently “5” nursing interfrecognized by ANA. 

*** Duplicates include entries where two or more of the N3 terminologies are considered a “major focus.” **** Formerly the Home Healthcare Classification.