Documentation burden is experienced by clinical end-users of the electronic health record. Flowsheet measure reuse and clinical concept redundancy are two contributors to documentation burden. In ...this paper, we described nursing flowsheet documentation hierarchy and frequency of use for one month from two hospitals in our health system. We examined respiratory care management documentation in greater detail. We found 59 instances of reuse of respiratory care flowsheet measure fields over two or more templates and groups, and 5 instances of clinical concept redundancy. Flowsheet measure fields for physical assessment observations and measurements were the most frequently documented and most reused, whereas respiratory intervention documentation was less frequently reused. Further research should investigate the relationship between flowsheet measure reuse and redundancy and EHR information overload and documentation burden.
Nurses have been required to provide more patient-centered, efficient, and cost effective care. In order to do so, they need to work at the top of their license. We conducted a time motion study to ...document nursing activities on communication, hands-on tasks, and locations (where activities occurred), and compared differences between different time blocks (7am-11am, 11am-3pm, and 3pm-7pm). We found that nurses spent most of their time communicating with patients and in patient rooms. Nurses also spent most of their time charting and reviewing information in EHR, mostly at the nursing station. Nurses' work was not distributed equally across a 12-hour shift. We found that greater frequency and duration in hands-on tasks occurred between 7am-11am. In addition, nurses spent approximately 10% of their time on delegable and non-nursing activities, which could be used more effectively for patient care. The study results provide evidence to assist nursing leaders to develop strategies for transforming nursing practice through re-examination of nursing work and activities, and to promote nurses working at top of license for high quality care and best outcomes. Our research also presents a novel and quantifiable method to capture data on multidimensional levels of nursing activities.
ABSTRACT Objective To map the terms recorded in medical records of patients with decompensated heart failure for nursing diagnoses and interventions from the NANDA International and Nursing ...Interventions Classification. Method This is an exploratory and descriptive research, carried out by a cross-mapping study. Data were collected from 107 medical records of a Hospital Institute in the city of Rio de Janeiro/Brazil, in a period between October 2017 to February 2019. The diagnoses and interventions mapped were assessed by four clinical experts. Data analysis was performed using the content validation index and the Fleiss Kappa. Results The most frequent nursing diagnoses were: risk for infection (74.8%), decreased cardiac output (55.1%) and excessive fluid volume (49.5%). The interventions were: vital signs monitoring (79.4%), fluid monitoring (72.9%) and positioning (52.3%). Conclusion The research mapped 32 titles of nursing diagnoses from NANDA-I and 21 nursing interventions from NIC. The diagnoses and interventions mapped will contribute to the quality of the nurses’ records and patient safety.
RESUMO Objetivo Mapear os termos registrados em prontuários de pacientes com insuficiência cardíaca descompensada para diagnósticos e intervenções de enfermagem da NANDA Internacional e Classificação de Intervenções de Enfermagem. Método Pesquisa exploratória, descritiva, realizada através do mapeamento cruzado. Os dados foram coletados em 107 prontuários de um hospital do município do Rio de Janeiro/RJ, no período entre outubro de 2017 e fevereiro de 2019. Os diagnósticos e intervenções mapeados foram avaliados por quatro peritos. A análise dos dados foi realizada pelo índice de validação de conteúdo e o Kappa de Fleiss. Resultados Os diagnósticos de enfermagem mais frequentes foram: risco de infecção (74,8%), débito cardíaco diminuído (55,1%) e volume de líquidos excessivo (49,5%). As intervenções foram: monitoração de sinais vitais (79,4%), monitoração hídrica (72,9%) e posicionamento (52,3%). Conclusão A pesquisa mapeou 32 títulos de diagnósticos de enfermagem da NANDA-I e 21 intervenções de enfermagem da NIC. Os diagnósticos e intervenções mapeados irão contribuir para a qualidade do registro de enfermeiros e segurança do paciente.
RESUMEN Objetivo Mapear los términos registrados en los registros médicos de pacientes con insuficiencia cardíaca descompensada para los diagnósticos e intervenciones de enfermería de NANDA International y la clasificación de las intervenciones de enfermería. Método Investigación exploratoria, descriptiva, realizada mediante mapeo cruzado. La recolección de datos se realizó en 107 historias clínicas de un hospital de la ciudad de Río de Janeiro / RJ, en el período comprendido entre octubre de 2017 y febrero de 2019. Los diagnósticos e intervenciones mapeados fueron evaluados por cuatro expertos. El análisis de los datos se realizó utilizando el índice de validación de contenido y el Kappa de Fleiss. Resultados: Los diagnósticos de enfermería más frecuentes fueron: riesgo de infección (74,8%), disminución del gasto cardíaco (55,1%) y volumen excesivo de líquidos (49,5%). Las intervenciones mapeadas fueron: monitoreo de signos vitales (79.4%) y posicionamiento (52.3%). Conclusión La investigación mapeó 32 títulos de diagnóstico de enfermería NANDA-I y 21 intervenciones de enfermería NIC. Los diagnósticos y las intervenciones mapeadas contribuirán a la calidad del registro de enfermeras y la seguridad del paciente.
Aims and objectives
To assess the quality of the advanced nursing process in nursing documentation in two hospitals.
Background
Various standardised terminologies are employed by nurses worldwide, ...whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike.
Design
Cross‐sectional study.
Methods
A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA‐International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0–58 points. Nursing records were dated 2012–2013 for Centre 1 and 2010–2011 for Centre 2.
Results
Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the ‘Nursing Diagnoses as Process’ dimension, whereas in the ‘Nursing Diagnoses as Product’, ‘Nursing Interventions’ and ‘Nursing Outcomes’ dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the ‘Nursing Interventions’ domain in Centre 1 and the ‘Nursing Diagnoses as Process’ and ‘Nursing Diagnoses as Product’ domains in Centre 2.
Conclusion
The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies.
Relevance to clinical practice
Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.
Background: Nurses constitute a significant portion of the health care workforce, playing a crucial role in enhancing the quality of hospital services, particularly in the context of nursing ...documentation to ensure the precise recording of patient information in accordance with established standards. This study examines the factors associated with implementing nursing documentation in a psychiatric hospital. Methods: This cross-sectional study was conducted in June 2023 in a psychiatric hospital in Indonesia. A convenience sampling method was employed to recruit 144 nurses working in the hospital. Data collection methods encompassed supervision questionnaires, Unified Motive Scales (UMS), and observation sheets used for recording nursing care activities. Data analysis involved the chi-square test and multiple logistic regression. Data analysis was performed with a significance level set at 0.05 and a CI of 95%, utilizing STATA 13. Results: We found significant associations between nursing documentation and supervision techniques (p = 0.01), need for power (p = 0.001), and need for affiliation (p = 0.002). Notably, the need for power emerged as the most influential factor in nursing documentation (odds ratio OR = 8.46; 95% CI, 3.53-20.28). Conclusion: These findings underscore the importance of supervision techniques, power needs, and affiliated needs in the context of nursing documentation. The statistically significant associations between these factors emphasize their role in ensuring accurate and comprehensive record-keeping within health care settings. Particularly noteworthy is the substantial influence of the need for power, with a high OR, suggesting that addressing power dynamics may be an essential strategy for improving nursing care documentation practices.
Aim
To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation.
Design
Systematic review of systematic reviews.
Data sources
We ...systematically searched the databases PubMed and CINAHL for the period 2007–April 2017. We also performed additional searches.
Review methods
Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis.
Results
Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence‐based instruments were described for assessing the quality of nursing documentation, such as the D‐Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user‐friendliness and development in consultation with nursing staff.
Conclusion
Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important for high‐quality nursing documentation. The lack of evidence‐based quality indicators presents a challenge in the pursuit of high‐quality nursing documentation.
Impact
There is uncertainty in nursing practice about which criteria have to be met to achieve high‐quality documentation.
Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important.
These findings can help nursing staff and care organizations enhance the quality of nursing documentation.
摘要
目的
了解护理文件质量标准、编制工具和要求方面现有循证概况
设计
对系统评价进行系统综述
数据来源
我们系统地搜索了文献数据库和护理学数据库,搜索范围从2007年至2017年8月。我们还进行了其他搜索
综述方法
两位研究人员各自分步综述、评估所选综述方法的质量以及使用预定义的提取格式提取数据。我们进行了描述性综合分析。
结果
包括11项系统评价,从遵循护理程序和使用标准化的护理术语的重要性方面讲述几个质量标准。此外,还叙述了一些用于评估文件质量的循证工具如DCatch。而且发现电子护理文件的格式和系统的几个要求涉及到用户友好与护理人员协商发展的重要性。
结论
使文件与护理程序保持一致、使用标准术语、采用用户友好的格式和系统,这些对于建立高质量护理文件似乎非常重要。建立高质量文件的一大挑战即为缺乏循证的质量指标。
影响
在护理实践中,无法确定为建立高质量文件必须要满足哪些标准。
使文件与护理程序保持一致、使用标准术语、采用用户友好的格式和系统似乎很重要。
这些发现可以帮助护理人员和保健组织提高护理文件编制质量。
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