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Mining Quality Documentation Data for Golden Outcomes

Washington County Public Health and Environment, Stillwater, Minnesota

Madeleine J. Kerr, PhD, RN

University of Minnesota School of Nursing, Minneapolis, Minnesota

Increased data reporting requirements, reimbursement changes, and automation capabilities provide new challenges for home health care and public health agencies today. These factors have become the impetus for computerization of practitioner documentation. Standardized documentation systems such as the Omaha System allow agencies to describe client needs, service delivery, and related client outcomes and to generate powerful data when used consistently and reliably in practice settings. This article offers practical suggestions for assuring data quality as well as simple, effective analysis and reporting strategies. Several figures depicting Omaha System documentation data from diverse programs are included as examples.

Key Words: Omaha System • OASIS • documentation • reliable data • reports

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