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Dang H, Stafseth SK. Documentation for Assessing Pain in Postoperative Pain Management Pre- and Post-intervention. J Perianesth Nurs 2023; 38:88-95. [PMID: 35970659 DOI: 10.1016/j.jopan.2022.05.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE Although Norwegian law requires the documentation of patients' care processes, including pain assessment, research has shown that the quality of postoperative documentation for assessing pain does not meet an acceptable standard and requires improvement. The purpose of this study was to investigate whether an educational intervention can increase nurses' documentation of postoperative pain assessments, alter patients' opioid consumption, and ensure that patients have at least one documented Numeric Rating Scale (NRS) ≤3 at rest before being discharged. A secondary aim was to investigate whether the nurses' education and experience influenced their pain assessments. DESIGN An observational study with a pre-post intervention. METHODS The study following a pre-post design involved documenting pain assessments of 304 patients undergoing cancer surgeries in a postoperative unit at the Norwegian Radium Hospital, Oslo University Hospital. In an educational intervention, two 45-minutes teaching sessions within two weeks, addressed validated pain assessment tools and the documentation of pain assessment. Descriptive frequency analysis and partial correlation with Pearson's r - value were used, with P < .05 indicating significance. FINDINGS Postintervention, pain assessments in general increased significantly from a mean of two times per patient to three times. Overall, the use of assessment tool Critical -Care Pain Observation Tool increased from 6.1% to 25.8%, opioid consumption increased in mean from 3.34 to 4.79 in milligram and the documentation at discharge increased from 81.4% to 91.4%. The documentation of nurses with more than 10 years' experience in the unit especially improved from 17.5% to 31.7%. CONCLUSIONS Educational intervention and reminders about basic systematic pain assessment and the evaluation of pain measures improved nurses' documentation of postoperative pain management and documentation at discharge. The findings underscore the importance of regularly ensuring the quality of patients' treatment by systematically documenting nurses' clinical tasks and the outcome of patients' care.
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Affiliation(s)
- Huong Dang
- Department of Postoperative and Intensive Care Nursing, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; MEVU Department, Lovisenberg Diaconal University College, Oslo, Norway.
| | - Siv K Stafseth
- Department of Postoperative and Intensive Care Nursing, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway; MEVU Department, Lovisenberg Diaconal University College, Oslo, Norway
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Näsman Y. The theory of caritative caring: Katie Eriksson’s theory of caritative caring presented from a human science point of view. Nurs Philos 2020; 21:e12321. [DOI: 10.1111/nup.12321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Yvonne Näsman
- Department of Caring Science Faculty of Education and Welfare Studies Åbo Akademi University Vaasa Finland
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Østensen E, Hardiker NR, Bragstad LK, Hellesø R. Introducing standardised care plans as a new recording tool in municipal health care. J Clin Nurs 2020; 29:3286-3297. [PMID: 32472572 DOI: 10.1111/jocn.15355] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/07/2020] [Accepted: 05/09/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions. BACKGROUND In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence-based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting. DESIGN An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research. METHODS Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records. RESULTS Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes "balancing between the old and the new care planning system," "considering the usefulness of standardised care plans as a source of information" and "balancing between overview and detail" reflect these findings. CONCLUSIONS Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan. RELEVANCE TO CLINICAL PRACTICE The structuring of nursing records is a fast-growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.
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Affiliation(s)
- Elisabeth Østensen
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nicholas R Hardiker
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Line Kildal Bragstad
- Institute of Health and Society and Research Center for Habilitation and Rehabilitation Services and Models (CHARM), University of Oslo, Oslo, Norway
| | - Ragnhild Hellesø
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Lumley E. Commentary: Designing and implementing an electronic nursing record to support compassionate and person-centred nursing practice in an acute hospital using practice development processes. J Res Nurs 2020; 25:254-255. [PMID: 34394633 DOI: 10.1177/1744987120918990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Elizabeth Lumley
- RGN/Research Associate, Medical Care Research Unit, Health Services Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
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5
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Martin K, Ham E, Hilton NZ. Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports. J Clin Nurs 2018; 27:3171-3178. [PMID: 29752835 DOI: 10.1111/jocn.14511] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process. BACKGROUND The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122-1131). DESIGN The project was a mixed-method, two-phase study that collected data from two sites. METHODS In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice. RESULTS Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration. CONCLUSIONS We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation. RELEVANCE TO CLINICAL PRACTICE Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases.
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Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,University of Ontario Institute of Technology, Oshawa, ON, Canada
| | - Elke Ham
- Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada
| | - N Zoe Hilton
- Waypoint Centre for Mental Health Care, Penetanguishene, ON, Canada.,University of Toronto, Toronto, ON, Canada
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6
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What is the problem with nursing documentation? Perspective of Indonesian nurses. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2018. [DOI: 10.1016/j.ijans.2018.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Kebede M, Endris Y, Zegeye DT. Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital. Inform Health Soc Care 2016; 42:290-302. [PMID: 27918228 DOI: 10.1080/17538157.2016.1252766] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Even though nursing care documentation is an important part of nursing practice, it is commonly left undone. The objective of this study was to assess nursing care documentation practice and the associated factors among nurses who are working at the University of Gondar Hospital. METHODS An institution-based cross-sectional study was conducted among 220 nurses working at the University of Gondar Hospital inpatient wards from March 20 to April 30, 2014. Data were collected using a structured and pre-tested self-administered questionnaire. Data were entered into Epi Info version 7 and analyzed with SPSS version 20. Descriptive statistics, bivariate, and multivariate logistic regression analyses were carried out. RESULTS Two hundred and six nurses returned the questionnaire. Good nursing care documentation practice among nurses was 37.4%. A low nurse-to-patient ratio AOR = 2.15 (95%CI [1.155, 4.020]), in-service training on standard nursing process AOR = 2.6 (95%CI[1.326, 5.052]), good knowledge AOR = 2.156(95% CI [1.092, 4.254]), and good attitude toward nursing care documentation AOR = 2.22 (95% CI [1.105, 4.471] were significantly associated with nursing care documentation practice. CONCLUSION Most of the nursing care provided remains undocumented. Nurse-to-patient ratio, in-service training, knowledge, and attitude of nurses toward nursing care documentation were factors associated with nursing care documentation practice.
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Affiliation(s)
- Mihiretu Kebede
- a Department of Health Informatics , Institute of Public Health, University of Gondar , Gondar , Ethiopia.,b Leibniz Prevention Institute for Research and Epidemiology-BIPS , Bremen , Germany.,c Department of Public Heath , University of Bremen , Bremen , Germany
| | - Yesuf Endris
- d Medical Director's Office , University of Gondar Hospital, University of Gondar , Gondar , Ethiopia
| | - Desalegn Tegabu Zegeye
- a Department of Health Informatics , Institute of Public Health, University of Gondar , Gondar , Ethiopia
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Nakate GM, Dahl D, Petrucka P, B. Drake K, Dunlap R. The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/ojn.2015.512113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Johnson M, Sanchez P, Suominen H, Basilakis J, Dawson L, Kelly B, Hanlen L. Comparing nursing handover and documentation: forming one set of patient information. Int Nurs Rev 2013; 61:73-81. [DOI: 10.1111/inr.12072] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. Johnson
- School of Nursing & Midwifery; University of Western Sydney; Sydney NSW Australia
- Centre for Applied Nursing Research (a joint facility of the South Western Sydney Local Health District and the University of Western Sydney); Sydney NSW Australia
| | - P. Sanchez
- Centre for Applied Nursing Research; Sydney NSW Australia
| | - H. Suominen
- NICTA; Canberra ACT Australia
- The Australian National University; Canberra ACT Australia
- University of Canberra; Canberra ACT Australia
| | - J. Basilakis
- University of Western Sydney; Sydney NSW Australia
| | - L. Dawson
- University of Wollongong; Wollongong NSW Australia
| | - B. Kelly
- The University of Melbourne; Melbourne Vic. Australia
| | - L. Hanlen
- NICTA; Canberra ACT Australia
- The Australian National University; Canberra ACT Australia
- University of Canberra; Canberra ACT Australia
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Adib Hajbaghery M, Moradi T. Quality of care for patients with traction in shahid beheshti hospital in 2012. ARCHIVES OF TRAUMA RESEARCH 2013; 2:85-90. [PMID: 24396800 PMCID: PMC3876554 DOI: 10.5812/atr.9127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 04/18/2013] [Accepted: 04/20/2013] [Indexed: 11/16/2022]
Abstract
Background With increasing incidence of traumatic fractures, the use of orthopedic intervention
such as traction has increased. Inappropriate traction care may cause substantial
morbidity and delay the patient rehabilitation. Objectives This study was conducted to evaluate the quality of care for patients with traction in
the orthopedic unit of Kashan's Shahid Beheshti Hospital, Kashan, Iran. Patients and Methods This observational study was conducted on 100 patients with traumatic fractures of hip
and femur bones who were admitted to Kashan Shahid-Beheshti Hospital during the first 6
months of 2012, and for whom skeletal or skin traction was performed. Data were
collected using a checklist including questions about the personal characteristics and
23 items related to care for patients with tractions. These items were in three domains
including caring while establishing traction, recording care and patient’s education.
Descriptive statistics were calculated and data were analyzed using the independent
sample t-test and Pearson correlation coefficient. Results The mean age of patients was 51.16 ± 23.28 years and 66% of them were male. In
total, 47% of the patients were treated by skin traction and 53% by skeletal traction.
The overall mean score of quality of care was 10.20 ± 2.64. Quality of establishing
traction was good in 55% of patients, but the quality of care was poor in the domains of
recording care (88%) and patient education (96%). Total mean of quality of care was
significantly different between male and female patients (P < 0.02). Conclusions The quality of care of patients with traction was not optimal. Therefore it is
necessary to improve measures in this area.
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Affiliation(s)
- Mohsen Adib Hajbaghery
- Trauma Nursing Research Center, Kashan University of
Medical Sciences, Kashan, IR Iran
- Corresponding author: Mohsen Adib Hajbaghery, Trauma
Nursing Research Center, Kashan University of Medical Sciences. Kashan, IR Iran. Tel.:
+98-3615550021, Fax: +98-3615556633, E-mail:
| | - Tayebeh Moradi
- Student Research Committee, Faculty of Nursing and
Midwifery, Kashan University of Medical Sciences, Kashan, IR Iran
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Keenan GM, Yakel E, Yao Y, Xu D, Szalacha L, Tschannen D, Ford Y, Chen YC, Johnson A, Lopez KD, Wilkie DJ. Maintaining a consistent big picture: meaningful use of a Web-based POC EHR system. Int J Nurs Knowl 2012; 23:119-33. [PMID: 23043651 PMCID: PMC3674817 DOI: 10.1111/j.2047-3095.2012.01215.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the hypothesis that Hands-on Automated Nursing Data System (HANDS) "big picture summary" can be implemented uniformly across diverse settings, and result in positive registered nurse (RN) and plan of care (POC) data outcomes across time. DESIGN In a longitudinal, multisite, full test study, a representative convenience sample of eight medical-surgical units from four hospitals (one university, two large community, and one small community) in one Midwestern state implemented the HANDS intervention for 24 (four units) or 12 (four units) months. MEASUREMENTS (a) RN outcomes-percentage completing training, satisfaction with standardized terminologies, perception of HANDS usefulness, POC submission compliance rate. (b) POC data outcomes-validity (rate of optional changes/episode); reliability of terms and ratings; and volume of standardized data generated. RESULTS One hundred percent of the RNs who worked on the eight study units successfully completed the required standardized training; all units selected participated for the entire 12- or 24-month designated period; compliance rates for POC entry at every patient hand-off were 78-92%; reliability coefficients for use of the standardized terms and ratings were moderately strong; the pattern of optional POC changes per episode declined but remained reasonable across time; and the nurses generated a database of 40,747 episodes of care. LIMITATIONS Only RNs and medical-surgical units participated. CONCLUSION It is possible to effectively standardize the capture and visualization of useful "big picture" healthcare information across diverse settings. Findings offer a viable alternative to the current practice of introducing new health information layers that ultimately increase the complexity and inconsistency of information for frontline users.
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Affiliation(s)
- Gail M Keenan
- College of Nursing, University of Illinois at Chicago, Chicago, IL, USA.
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12
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Patients' perceptions of nurses' behaviour that influence patient participation in nursing care: a critical incident study. Nurs Res Pract 2011; 2011:534060. [PMID: 21994832 PMCID: PMC3169855 DOI: 10.1155/2011/534060] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 02/06/2011] [Accepted: 02/20/2011] [Indexed: 11/25/2022] Open
Abstract
Patient participation is an important basis for nursing care and medical treatment and is a legal right in many Western countries. Studies have established that patients consider participation to be both obvious and important, but there are also findings showing the opposite and patients often prefer a passive recipient role. Knowledge of what may influence patients' participation is thus of great importance. The aim was to identify incidents and nurses' behaviours that influence patients' participation in nursing care based on patients' experiences from inpatient somatic care. The Critical Incident Technique (CIT) was employed. Interviews were performed with patients (n = 17), recruited from somatic inpatient care at an internal medical clinic in West Sweden. This study provided a picture of incidents, nurses' behaviours that stimulate or inhibit patients' participation, and patient reactions on nurses' behaviours. Incidents took place during medical ward round, nursing ward round, information session, nursing documentation, drug administration, and meal.
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Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs 2011; 67:1858-75. [PMID: 21466578 DOI: 10.1111/j.1365-2648.2011.05634.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation. INTRODUCTION Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings. DATA SOURCES Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010. REVIEW METHODS A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted. RESULTS Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality. CONCLUSION Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.
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Affiliation(s)
- Ning Wang
- Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia
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Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract 2010; 16:112-24. [PMID: 20487056 DOI: 10.1111/j.1440-172x.2009.01815.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to synthesize all relevant information about nursing documentation and present the essential aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude, audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational, patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature, research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of the barriers or more controversial aspects of the final policy are described.
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Affiliation(s)
- Diana Jefferies
- Centre for Applied Nursing Research, Liverpool BC, New South Wales 1871, Australia.
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Laitinen H, Kaunonen M, Astedt-Kurki P. Patient-focused nursing documentation expressed by nurses. J Clin Nurs 2010; 19:489-97. [PMID: 20500288 DOI: 10.1111/j.1365-2702.2009.02983.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The aim of the study was to investigate what expressions nurses use when documenting patient-focused nursing care in electronic patient records. BACKGROUND Much effort has been made in the development of nursing documentation. Many studies have found inadequate reporting, focused more on tasks and treatment than on the patient's voice. Electronic patient record-systems have been introduced, bringing new challenges because of unfamiliarity with computers. Electronic patient records have caused dissatisfaction and frustration, however, some studies show improvement in documentation given enough time and effort. Electronic patient record documentation is an integral part of patient-focused care and thus needs to be investigated. DESIGN The study is based on the grounded theory approach, as developed by Strauss and Corbin. METHODS Forty electronic patient records were analysed, considering whether nurses' written expressions reflected a patient-focused approach. An inductive qualitative method was used, involving constant comparative analysis, up to axial coding. RESULTS Three categories emerged from the data: Patient's voice: the patient has expressed his/her thoughts, which are written by the nurse, Nurse's view: the nurse recounts the patient's own thoughts, state or situation and mutual view in patient-nurse relationship: the documentation describes the patient-nurse relationship. CONCLUSIONS This study found that the nursing documentation was patient-focused, to some extent. This is significant because nursing documentation represents much more than simply a record of the continuity of care. Many topics for further studies were presented, e.g., the timing of documentation and the differences between the mode of nursing and the documentation. RELEVANCE TO CLINICAL PRACTICE The presented findings may be helpful in the development of nursing documentation in electronic patient records and in nursing practice generally. Highlighting the patient's voice could become an effective tool in nursing and its documentation, saving time and getting clear information for improving the patient's care.
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Affiliation(s)
- Heleena Laitinen
- Department of Nursing Science, University of Tampere and Science Centre, Pirkanmaa Hospital District, Tampere, Finland.
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Dunnion ME, Griffin M. Care planning in the emergency department. Int Emerg Nurs 2009; 18:67-75. [PMID: 20382367 DOI: 10.1016/j.ienj.2009.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 08/14/2009] [Accepted: 10/03/2009] [Indexed: 11/27/2022]
Abstract
There are many demands placed on staff working in emergency departments such as the currently witnessed overcrowding, bed shortages and long waiting times for patients. Despite these demands nursing care needs to be carefully assessed, planned and documented. This study aimed to examine attitudes of staff towards the use of a nursing care plan in the emergency department. The sample comprised the total population (n=38) of all nursing staff working in an emergency department at one regional general hospital in the Republic of Ireland. The method adopted was a survey approach which employed the use of standardised questionnaires comprising both open and closed questioning styles. Raw statistical data were analysed using SPSS for Windows while the qualitative data arising from the open-ended questions were manually analysed for themes. The data obtained in this study identified that care plans were valued by respondents, stating that they contribute to holism, increased nurse/patient contact time and better communication. The findings also identified that there is a need for continuing education, further research and a need to address issues in relation to specific patient groups, including paediatrics, minor injuries, mental health and the elderly attending the emergency department.
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Affiliation(s)
- Mary E Dunnion
- Department of Nursing and Health Studies, Letterkenny Institute of Technology, Co. Donegal, Ireland.
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Saranto K, Kinnunen UM. Evaluating nursing documentation - research designs and methods: systematic review. J Adv Nurs 2009; 65:464-76. [DOI: 10.1111/j.1365-2648.2008.04914.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Persenius MW, Hall-Lord ML, Bååth C, Larsson BW. Assessment and documentation of patients’ nutritional status: perceptions of registered nurses and their chief nurses. J Clin Nurs 2008; 17:2125-36. [DOI: 10.1111/j.1365-2702.2007.02202.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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