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Nursing Documentation (nursing + documentation)
Selected AbstractsEffects of Computerized Provider Order Entry and Nursing Documentation on WorkflowACADEMIC EMERGENCY MEDICINE, Issue 10 2008Phillip V. Asaro MD Abstract Objectives:, The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). Methods:, The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions. Results:, There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and/or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. Conclusions:, The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider,computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected. [source] Fatigued Elderly Patients With Chronic Heart FailureINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003Anna Ehrenberg PURPOSE To compare descriptions of fatigue based on the NANDA characteristics from interviews with elderly people with congestive heart failure (CHF) and data recorded by nurses at a Swedish outpatient heart failure clinic. METHODS Patients were screened for moderate to severe CHF. A total of 158 patients were interviewed using a revised form of the Fatigue Interview Schedule (FIS) based on the NANDA characteristics. Of these patients, half (n= 79) were offered visits at a nurse-monitored heart failure clinic. Nursing documentation of fatigue at the heart failure clinic was reviewed based on the NANDA characteristics and compared with the content in the patient interviews. FINDINGS Tiredness was documented in 43 (75%) records and indicated in 36 patients based on patient scores on the FIS (X,= 5.5; range 1,9). The most frequently recorded observation related to fatigue was the symptom emotionally labile or irritable, followed by notes on lack of energy and decreased performance. Patients' descriptions of their fatigue were expressed as a decreased ability to perform and a perceived need for additional energy. Results indicated poor concordance in patients' descriptions and record content concerning fatigue. Whereas patients emphasized the physical characteristics of fatigue, nurses emphasised the emotional features. Decreased libido was linked to fatigue according to the patients but not according to the nurses' records. Whereas cognitive characteristics of fatigue occurred rarely in the records, they were more frequent in the patient interviews. DISCUSSION Symptoms such as irritability and accident-proneness may be seen as manifestations of the patients' experiencing the need for more energy or a feeling of decreased performance. These consequences of being fatigued, rather than the different dimensions of fatigue, seemed to have been easy for the nurses to observe and document. Earlier studies indicate that poor observation, medication, and diet in patients with heart failure might partly be explained by cognitive impairment. CONCLUSIONS Findings of this study highlight the need for nurses to pay attention to the experience of fatigue in patients who suffer from CHF, and to validate their observations with the patients own expressions. Using the patients' words and expressions and the diagnostic characteristics of fatigue in recording can support the nurses in developing both understanding of patients living with CHF and strategies to help patients cope with their restricted ability in daily life. [source] How do nurses record pedagogical activities?JOURNAL OF CLINICAL NURSING, Issue 10 2007Nurses' documentation in patient records in a cardiac rehabilitation unit for patients who have undergone coronary artery bypass surgery Aims., To describe the use of pedagogically related keywords and the content of notes connected to these keywords, as they appear in nursing records in a coronary artery bypass graft (CABG) surgery rehabilitation unit. Background., Nursing documentation is an important component of clinical practice and is regulated by law in Sweden. Studies have been carried out in order to evaluate the educational and rehabilitative needs of patients following CABG surgery but, as yet, no study has contained an in-depth evaluation of how nurses document pedagogical activities in the records of these patients. Methods., The records of 265 patients admitted to a rehabilitation unit following CABG surgery were analysed. The records were structured in accordance with the VIPS model. Using this model, pedagogically related keywords: communication, cognition/development and information/education were selected. The analysis of the data consisted of three parts: the frequency with which pedagogically related keywords are used, the content and the structure of the notes. Results., Apart from the term ,communication', pedagogically related keywords were seldom used. Communication appeared in all records describing limitations, although no explicit reference was made to pedagogical activities. The notes related to cognition/development were grouped into the following themes: nurses' actions, assessment of knowledge and provision of information, advice and instructions as well as patients' wishes and experiences. The themes related to information were the provision of information and advice in addition to relevant nursing actions. The structure of the documentation was simple. Conclusions., The documentation of pedagogical activities in nursing records was infrequent and inadequate. Relevance to clinical practice., The patients' need for knowledge and the nurses' teaching must be documented in the patient records so as to clearly reflect the frequency and quality of pedagogical activities. [source] Nursing documentation of postoperative pain managementJOURNAL OF CLINICAL NURSING, Issue 6 2002Ewa Idvall PhD Summary ?,Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. ?,The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. ?,The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. ?,The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. ?,The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. ?,The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware. [source] An Internet-Based Survey of Icelandic Nurses on Their Use of and Attitudes Toward NANDA, NIC, and NOCINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003Gyda Bjornsdottir PURPOSE To gain understanding of how Icelandic nurses can be supported during a mandated change to the use of NANDA and NIC in clinical documentation practices. METHODS All members of the Icelandic Nurses Association of working age were invited to participate in an Internet-based survey. Each nurse was assigned a unique password mailed to his/her home along with information on how to access the survey Web site. Each nurse could submit answers only once. On submission, data were automatically coded and saved in a database under encrypted numerical identifiers. FINDINGS A total of 463 nurses (18% response rate) participated by submitting answers. The sample was representative of the population in terms of demographic characteristics. Information resources most valued when planning nursing care included text-based progress notes (77%), nursing care plans (52%), doctor's orders (49%), verbal information (48%), and documented nursing diagnoses (37%). Of the participants, 58% said NANDA was used in their workplace; 28% said no standardized nursing documentation was used; 19% reported using NIC always or sometimes when documenting nursing interventions; and 20% never used NIC. NOC use was reported only by researchers. Of the sample, 86% reported that it is important or necessary for nurses to standardize documentation practices; 30% found NANDA useful in education; 56% found it useful for clinical work; 17% for research; and 7% found it not useful at all. Nine percent believed that NANDA diagnoses were not descriptive enough of patients' problems, and 23% found their wording problematic. No statistically significant differences were found between reported use of or attitudes toward NANDA and NIC when comparing nurses who use electronic patient record systems that support NANDA and NIC documentation and those who use paper documentation only. DISCUSSION The sample may have been somewhat biased toward computer use and classification system use for standardized and computerized documentation. However, results indicate that although Icelandic nurses give free-text progress notes and verbal information a higher priority than nursing diagnoses as an information resource for care planning, they have a positive attitude toward NANDA. NANDA and NIC are still used inconsistently in clinical practice, and 28% of participants claimed not to use any form of standardized documentation. CONCLUSIONS In an effort to standardize clinical documentation among nurses, Icelandic health authorities must follow their documentation mandates with educational and technologic support to facilitate the use of NANDA, NIC, and (after its translation) NOC in nursing documentation practices. Electronic patient record system developers must find ways to further facilitate standardized nursing documentation because currently there seems to be no difference between users and nonusers in terms of how they use NANDA and NIC in their documentation practices. [source] Evaluating nursing documentation , research designs and methods: systematic reviewJOURNAL OF ADVANCED NURSING, Issue 3 2009Kaija Saranto Abstract Title., Evaluating nursing documentation , research designs and methods: systematic review. Aim., This paper is a report of a review conducted to assess the research methods applied in the evaluation of nursing documentation. Data sources., The material was drawn from three databases: CINAHL, PubMed and Cochrane using the keywords nursing documentation, nursing care plan, nursing record system, evaluation and assessment. The search was confined to relevant electronically-retrievable studies published in the English language from 2000 to 2007. This yielded 41 studies, including two reviews. Methods., Content analysis produced a classification into three themes: nursing documentation, patient-centred documentation and standardized documentation. Each study was assessed according to its research design, methodology, sample size and focus of data collection. In addition, the studies categorized under the heading of standardized documentation were assessed in terms of their outcomes. Results., Most of the studies (n = 19) focused on patient-centred documentation. Most (n = 20) were retrospective studies and used data collected from patient records (n = 35). An audit instrument was used to assess nursing documentation in almost all the studies. Studies classified under the heading of standardized documentation showed more positive than negative effects with respect to quality, the nursing process and terminology use, knowledge level and acceptance of computer use in documentation. Conclusion., The use of structured nursing terminology in electronic patient record systems will extend the scope of documentation research from assessing the quality of documentation to measuring patient outcomes. More data should also be collected from patients and family members when evaluating nursing documentation. [source] Postdischarge nursing interventions for stroke survivors and their familiesJOURNAL OF ADVANCED NURSING, Issue 2 2004Kelly L. McBride MSc RN Background. The physical, cognitive, and emotional sequelae of stroke underscore the need for nursing interventions across the continuum of care. Although there are several published studies evaluating community interventions for stroke survivors, the nursing role has not been clearly articulated. Aim. The aim of this paper is to report a study to describe, using a standardized classification system, the nursing interventions used with stroke survivors during the initial 6 weeks following discharge home. Methods. In the context of a randomized controlled trial, two nurse case managers provided care to 90 community-dwelling stroke survivors who were assigned to the intervention arm of the trial. The nursing documentation was analysed, using the Nursing Intervention Classification (NIC) system, to identify and quantify the interventions that were provided. Findings. Stroke survivors received, on average, six different interventions. There was a trend for those who were older, more impaired, and who lived alone to receive more interventions. The most commonly reported interventions included those directed towards ensuring continuity of care between acute and community care, family care, and modifying stroke risk factors. The study was limited to the nursing documentation, which may represent an underestimation of the care delivered. Conclusions. The NIC system was useful in capturing the interventions delivered by the nurse case managers. Nursing interventions are often not clearly articulated and less often use standardized terminology. Describing nursing activities in a standard manner will contribute to an increase in nursing knowledge and to evidence-based practice. [source] The development of pressure ulcers in patients with hip fractures: inadequate nursing documentation is still a problemJOURNAL OF ADVANCED NURSING, Issue 5 2000Lena Gunningberg MSC RN The aims of the study were to investigate, on a daily basis: (i] the development and progress of pressure ulcers, (ii) the documented nursing interventions for prevention and treatment of pressure ulcers, and (iii) when nursing interventions regarding prevention and treatment of pressure ulcers were documented, in relation to patient risk status and the development of pressure ulcers. The study design was prospective, comparative and descriptive. A total of 55 patients with hip fracture were included. To facilitate the nurse's assessment, a ,pressure ulcer card' was developed, consisting of the Modified Norton Scale (MNS) and descriptions of the four stages of pressure ulcers. The incidence of pressure ulcers was 55%. The mean rank of the lowest MNS score was significantly lower for patients who developed pressure ulcers than for patients without pressure ulcers. The majority of the pressure ulcers occurred between admission to the ward and the fourth day after surgery. Documented interventions regarding prevention and treatment were: repositioning, overlays, cushions, use of lotion and observation. The mean number of interventions per patient was 2·2 for patients who developed pressure ulcers during their hospital stay. The comprehensiveness and quality of the nursing record was unsatisfactory, and only three nursing records reached the level required by Swedish law. Preventive interventions such as repositioning were documented when the pressure ulcer had already occurred. The lack of nursing documentation regarding prevention and treatment of pressure ulcers may indicate that nurses did not identify pressure ulcers as a prioritized nursing problem for this patient group. The Modified Norton Scale could be a valuable tool for nurses, both identifying the patient at risk and acting as a guide for nursing interventions. The study was approved by the ethics committee of the Faculty of Medicine at Uppsala University. [source] Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIOJOURNAL OF CLINICAL NURSING, Issue 7 2009Maria Müller-Staub Aims and objectives., This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed. Background., Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation. Design., A qualitative design was used for instrument development. Methods., Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalised into items and eight experts assessed face and content validity of the Q-DIO. Results., Criteria were developed and operationalised into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88·25% agreement for the scores assigned to the 29 items of the Q-DIO. Conclusions., The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended. Relevance to clinical practice., Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records. [source] Older patients with chronic heart failure within Swedish community health care: a record review of nursing assessments and interventionsJOURNAL OF CLINICAL NURSING, Issue 1 2004Anna Ehrenberg PhD Background., Older patients with chronic heart failure constitute a large group within community home care that is at high risk for re-hospitalization. However, hospital readmission can be prevented if early signs of deterioration are recognized and proper interventions applied. Aims and objectives., The aim of the study was to audit nursing care for older chronic heart failure patients within the Swedish community health care system. Design., The study adopted a retrospective descriptive design. Methods., In a Swedish urban municipality nursing documentation from 161 records on patients diagnosed with chronic heart failure was collected retrospectively from community nursing home care units. Patient records were reviewed for characteristics of nursing care and assessed for comprehensiveness in recording. Results., The main results showed that medical care of patients with chronic heart failure was poorly recorded, making it possible only to follow fragments of the care process. The nursing notes showed poor adherence to current clinical guidelines. Only 12% of the records contained notes on patients' body weight and only 4% noted patients' knowledge about chronic heart failure. When interventions did occur, they largely consisted of drug administration. Conclusions., The findings revealed flaws in the recording of specific assessment and interventions as well as poor adherence to current international clinical guidelines. Relevance to clinical practice., Supportive guidelines available at the point of care are needed to enhance proper community-based home health care for older patients with chronic heart failure. [source] Nursing documentation of postoperative pain managementJOURNAL OF CLINICAL NURSING, Issue 6 2002Ewa Idvall PhD Summary ?,Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. ?,The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. ?,The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. ?,The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. ?,The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. ?,The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware. [source] A Delphi survey of evidence-based nursing priorities in Hong KongJOURNAL OF NURSING MANAGEMENT, Issue 5 2002C PSYCHOL, Peter French PhD The purpose of this study was to inform an evidence-based nursing development project within the Hospital Authority, Hong Kong. It considered the specific question of: what are the nursing practice issues which need to be addressed as a matter of priority in order to improve nursing practice, the quality of care or develop some aspect of nursing practice. A three round Delphi survey was adopted. The methodological problems associated with the use of the Delphi method are addressed. An expert panel consisting of 190 Department Operations Managers (nurses) was identified. The data collection focused on issues related to nursing skills and client care and excluded management or educational issues. Agreed categories were prioritized in the final round by utilizing a 11-point rating scale. The group mean score for each category was calculated and rank ordered. The results provided 45 categories that reflected the nursing practice priorities that required more research evidence to guide practice. The top five ranked items were: nurse patient communication, resuscitation, administration of medicines, counselling and nursing documentation. The top 10 items were used to inform the advisory and selection processes for the evidence-based practice development project. [source] Modes of rationality in nursing documentation: biology, biography and the ,voice of nursing'NURSING INQUIRY, Issue 2 2005Abbey Hyde Modes of rationality in nursing documentation: biology, biography, and the ,voice of nursing' This article is based on a discourse analysis of the complete nursing records of 45 patients, and concerns the modes of rationality that mediated text-based accounts relating to patient care that nurses recorded. The analysis draws on the work of the critical theorist, Jürgen Habermas, who conceptualised rationality in the context of modernity according to two types: purposive rationality based on an instrumental logic, and value rationality based on ethical considerations and moral reasoning. Our analysis revealed that purposive rationality dominated the content of nursing documentation, as evidenced by a particularly bio-centric and modernist construction of the workings of the body within the texts. There was little reference in the documentation to central themes of contemporary nursing discourses, such as notions of partnership, autonomy, and self-determination, which are associated with value rationality. Drawing on Habermas, we argue that this nursing documentation depicted the colonisation of the sociocultural lifeworld by the bio-technocratic system. Where nurses recorded disagreements that patients had with medical regimes, the central struggle inherent in the project of modernity became transparent , the tension between the rational and instrumental control of people through scientific regulation and the autonomy of the subject. The article concludes by problematising communicative action within the context of nursing practice. [source] Effects of Computerized Provider Order Entry and Nursing Documentation on WorkflowACADEMIC EMERGENCY MEDICINE, Issue 10 2008Phillip V. Asaro MD Abstract Objectives:, The objective was to measure the effects of the implementation of computerized provider order entry (CPOE) and electronic nursing documentation on provider workflow in the emergency department (ED). Methods:, The authors performed a before-and-after time-motion study of the activities of physicians and nurses. The percentages of time spent in task categories were calculated by provider session and averaged across provider sessions. Results:, There was a shift in physician time from working with paper alone, 13.1% to 9.6% (p = 0.05), to working with paper while using a computer, 1.6% to 4.3% (p = 0.02), and an increase in time spent working on computer and/or paper from 30.0% to 38.9% (p = 0.02). For nurses, the increase in time spent on computer from 9.5% to 25.7% (p < 0.01) was offset by a decrease in time spent working with paper from 16.5% to 1.8% (p < 0.01). Direct care decreased minimally for nurses from 56.9% to 55.3% (p = 0.69), but from 36.8% to 29.1% (p = 0.07) for physicians, approaching statistical significance. Care planning decreased for nurses from 9.4% to 6.4% (p = 0.04) and from 21.7% to 19.5% (p = 0.60) for physicians. Conclusions:, The net effects of an implementation on provider workflow depend not only on changes in tasks directly related to the provider,computer interface, but also on changes in underlying patient care processes and information flows. The authors observed an unanticipated shift in physician time from interacting with nurses and patients toward retrieving information from the electronic patient record. Implementers should carefully consider how implementations will affect information flow and then expect the unexpected. [source] | ||||||||||