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Progress Notes (progress + note)

Distribution by Scientific Domains
Medical Sciences75%

Selected Abstracts

An Internet-Based Survey of Icelandic Nurses on Their Use of and Attitudes Toward NANDA, NIC, and NOC

INTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003
Gyda 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]

Comparison of Treatment Result and Compliance between Private Practice Medicaid and Non-Medicaid Orthodontic Patients , A Brief Communication

JOURNAL OF PUBLIC HEALTH DENTISTRY, Issue 3 2008
Steven Dickens
Abstract Treatment result and compliance for orthodontic Medicaid patients were assessed and compared to non-Medicaid patients of similar initial severity. All 55 North Carolina practices providing orthodontic treatment covered by Medicaid were asked to submit their last five Medicaid cases and five non-Medicaid cases of similar initial treatment complexity. Nine practices agreed to participate. Initial models, final models, and progress notes were obtained for all subjects. Casts were scored using the Peer Assessment Rating (PAR) Index to assess initial and posttreatment orthodontic status, and progress notes were reviewed for compliance data. No clinically important differences were seen between the Medicaid and non-Medicaid groups with respect to initial PAR, final PAR, percent PAR reduction, broken appointments, broken appliances, or poor oral hygiene. In this study, Medicaid and non-Medicaid patients did not differ substantially with respect to effectiveness of treatment received or their compliance with treatment. [source]

Do we know when our clients get worse? an investigation of therapists' ability to detect negative client change

CLINICAL PSYCHOLOGY AND PSYCHOTHERAPY (AN INTERNATIONAL JOURNAL OF THEORY & PRACTICE), Issue 1 2010
Derek Hatfield
Abstract Routine clinical judgment is often relied upon to detect client deterioration. How reliable are therapists' judgments of deterioration? Two related studies were conducted to investigate therapist detection of client deterioration and therapist treatment decisions in situations of deterioration. The first study examined therapists' ability to detect client deterioration through the review of therapy progress notes. Therapist treatment decisions in cases of client deterioration were also explored. Therapists had considerable difficulty recognizing client deterioration, challenging the assumption that routine clinical judgment is sufficient when attempting to detect client deterioration. A second study was a survey of therapists asking how they detect client deterioration and what treatment decisions they make in response. Symptom worsening was the most commonly stated cue of deterioration. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: , Clinicians may have a difficult time detecting when their client's symptoms are worsening. , Outcome assessment strategies do exist to help clinicians detect client deterioration. [source]