The Nursing clinics of North America
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Public health nurses reminisce about the days when writing about the care given was a small part of the workday. Third parties certainly were not as interested in what was documented then as they are today. Perhaps the state would admonish an agency about the fact that goals were missing in the charts, but no one talked about documentation being the key to reimbursement and agency survival. ⋯ It is a vehicle for communicating from one professional to another about the status and needs of the patient. In fact, the chart is often the only means to demonstrate that professional standards, state regulations, and the criteria for reimbursement were met. However, to the extent that charting significantly interferes with the amount of time nurses can spend with patients, it must be limited.(ABSTRACT TRUNCATED AT 250 WORDS)