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Recognizing the Need for Standardized Documentation and Classifying Patient Needs

Karen S. Martin

Alice R. Swan

Total quality management is a data- driven process of continuously improving care. Unless standardized data that can be converted to numbers for analysis are incorporated into routine clinical documentation, the cost of doing total quality management is prohibitive. The Omaha System is useful for total quality management, since it is one of the nationally recognized classification systems for standardizing nursing diagnoses, interventions, and rating outcomes. The Omaha System is described in this article, including the research base for demonstrating the usefulness of the system. An example of using the Omaha System for total quality management is provided, including a standardized care plan for home care clients with chronic obstructive pulmonary disease.

Key Words: chronic obstructive pulmonary disease, home care • Omaha System • standardized information • total quality management

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