Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

Social science and linguistic text analysis of nurses' records: a systematic review and critique

The two aims of the paper were to systematically review and critique social science and linguistic text analyses of nursing records in order to inform future research in this emerging area of research. Systematic searches in reference databases and in citation indexes identified 12 articles that included analyses of the social and linguistic features of records and recording. Two reviewers extracted data using established criteria for the evaluation of qualitative research papers. A common characteristic of nursing records was the economical use of language with local meanings that conveyed little information to the uninitiated reader. Records were dominated by technocratic-medical discourse focused on patients' bodies, and they depicted only very limited aspects of nursing practice. Nurses made moral evaluations in their categorisation of patients, which reflected detailed surveillance of patients' disturbing behaviour. The text analysis methods were rarely transparent in the articles, which could suggest research quality problems. For most articles, the significance of the findings was substantiated more by theoretical readings of the institutional settings than by the analysis of textual data. More probing empirical research of nurses' records and a wider range of theoretical perspectives has the potential to expose the situated meanings of nursing work in healthcare organisations.

Implementation of Free Text Format Nursing Diagnoses at a University Hospital's Medical Department. Exploring Nurses' and Nursing Students' Experiences on Use and Usefulness. A Qualitative Study

Background. Nursing documentation has long traditions and represents core element of nursing, but the documentation is often criticized of being incomplete. Nursing diagnoses are an important research topic in nursing in terms of quality of nursing assessment, interventions, and outcome in addition to facilitating communication and continuity. Aim. The aim of this study was to explore the nurses' and nursing students' experiences after implementing free text format nursing diagnoses in a medical department. Method. The study design included educational intervention of free text nursing diagnoses. Data was collected through five focus group interviews with 18 nurses and 6 students as informants. The data was analyzed using qualitative content analysis. Results. The informants describe positive experiences concerning free text format nursing diagnoses' use and usefulness; it promotes reflection and discussion and is described as a useful tool in the diagnostic process, though it was challenging to find the diagnosis' appropriate formulation. Conclusion. Our findings indicate a valid usability of free text format nursing diagnoses as it promotes the diagnostic process. The use seems to enhance critical thinking and may serve as valuable preparation towards an implementation of standardized nursing diagnoses. Use and support of key personnel seem valuable in an implementation process.

[Treatment of skin lesions in newborn children: meeting the needs of nursing staff]

OBJECTIVE

To understand, together with nursing staff, the care needed to treat skin lesions in newborn children hospitalized in a neonatal unit.

METHOD

Qualitative research, of the convergent care type. The data was collected through semi-structured interviews, which were conducted from November to December 2012, in the neonatal unit of a hospital in southern Brazil. The participants were four auxiliary nurses, six nursing technicians and four nurses.

RESULTS

The following three categories were designated: questions about what can be used in relation to newborn children; hospitalization can cause lesions on the skin of newborn children; and knowledge about care promotes professional autonomy.

CONCLUSION

There is an urgent need for staff to know more about the treatment of skin lesions, which would provide safer care for newborn children and would also support the autonomy of professional nurses in providing that care.


Assessment of quality in psychiatric nursing documentation - a clinical audit

Background

Quality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital.

Method

A cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points).

Results

The item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items.

Conclusions

Deficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.

Utilization of a cardiometabolic health nurse - a novel strategy to manage comorbid physical and mental illness

BACKGROUND

Comorbid chronic illnesses, such as cardiovascular disease, respiratory conditions, and type 2 diabetes are common among people with serious mental illness. Management of comorbid illness in the mental health setting is sometimes ad hoc and poorly delivered. Use of a cardiometabolic health nurse (CHN) is proposed as one strategy to improve the delivery of physical health care to this vulnerable population.

OBJECTIVE

To report the CHN's utilization of primary care and allied health referrals from a trial carried out in a regional community mental health service.

DESIGN

Feasibility study. Mental health consumers were referred by their case manager or mental health nurse to the CHN. The CHN coordinated the physical health care of community-based mental health consumers by identifying the need for, and providing referrals to, additional services, including primary care, allied health, and community-based services.

RESULTS

Sixty-two percent of participants referred to the CHN received referrals for primary care, allied health, and community-based services. Almost all referrals received follow-up by the CHN. Referrals were most commonly directed to a general practitioner and for nurse-delivered services.

CONCLUSION

The CHN role shows promise in coordinating the physical health of community-based mental health consumers. More studies on role integration and development of specific outcome measurement tools are needed. Journal of Comorbidity 2014;4:22-28.

Implementation of a next-generation electronic nursing records system based on detailed clinical models and integration of clinical practice guidelines

Objectives

The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system.

Methods

A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system.

Results

The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines.

Conclusions

An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.

An integrative literature review on accuracy in anesthesia information management systems

An anesthesia information management system is a dynamic electronic documentation system that generates the legal records of patient care while the patient is receiving anesthesia. The generated documentation can be used to guide patient care, facilitate billing for services, and be used for clinical research. The purpose of this article was to synthesize the previous empirical and theoretical literature pertaining to the concept of accuracy in documentation in a wide range of disciplines in order to refine the concept and more effectively guide future research, clinical practice, and policy development in anesthesia informatics. The basic definition of accuracy is generally agreed upon, but the exact method of measuring accuracy is very different across disciplines. The concept of accuracy is defined in the published literature using the terms completeness, comprehensiveness, correctness, precision, legibility, readability, quantity of data, redundancy of data, clearness of data, concordance of data, and legitimacy. In nursing, accuracy can be defined as the presence of correct data that provide a complete, comprehensive, and precise representation of patient care. In anesthesia, accuracy is often defined in terms of correctness and completeness of data. Correctness, completeness, comprehensiveness, and precision are the primary constituents of accuracy with each discipline emphasizing different aspects.

Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting

PURPOSE

This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology.

METHODS

An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review.

FINDINGS

Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans.

CONCLUSIONS AND IMPLICATIONS

The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care.

CLINICAL RELEVANCE

The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care.

Quality improvement in clinical documentation: does clinical governance work?

Introduction

The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation.

Methods

A quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist.

Results

There were no differences between a nurse’s demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program.

Conclusion

Although some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.

Contribuição das linguagens padronizadas para a produção do conhecimento, raciocínio clínico e prática clínica da Enfermagem

Os sistemas de linguagens padronizadas são instrumentos importantes para lidar com a crescente complexidade do cuidado de enfermagem. Neste artigo os autores apresentam os principais benefícios que o uso desses sistemas oferece para o raciocínio clínico requerido no cuidado de enfermagem, para a construção e organização do conhecimento da disciplina e para a prática clínica de enfermagem. As potenciais contribuições dos sistemas de linguagens padronizadas nesses campos derivam do fato de tais sistemas oferecerem estrutura formal para apoiar o raciocínio clínico, organizar o conhecimento e a experiência de enfermagem.

Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes

PURPOSE

To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment.

METHODS

This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated.

RESULTS

Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms).

CONCLUSIONS

Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

BACKGROUND

The nurses' ability to document patient's status, problems and progress is an important issue in patients' safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians.

OBJECTIVES

This study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts.

DESIGN

Observational, longitudinal, multicentre study.

SETTING

A total of 8 hospitals representing 162 acute medical-surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included.

PARTICIPANTS

Overall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%).

METHODS

The main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals.

RESULTS

Most of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients' problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25-51.65) or Acute pain (49.6%; CI: 49.49-49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking.

CONCLUSIONS

Results for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting.

Nursing Documentation in Long-Term Care Settings

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.

Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities

PURPOSE

To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records.

METHODS

Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level.

RESULTS

Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p<0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p<0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p<0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p<0.01), suggesting more items designed in a form, more information would be captured.

CONCLUSION

Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content.