•Nurses mapped EHR-extracted local care plan terms to standardized terminologies.•All local care plan terms were mapped to standardized labels, classes, or domains.•We standardized nursing data for ...integration into clinical data research networks.
Care plans documented by nurses in electronic health records (EHR) are a rich source of data to generate knowledge and measure the impact of nursing care. Unfortunately, there is a lack of integration of these data in clinical data research networks (CDRN) data trusts, due in large part to nursing care being documented with local vocabulary, resulting in non-standardized data. The absence of high-quality nursing care plan data in data trusts limits the investigation of interdisciplinary care aimed at improving patient outcomes.
To map local nursing care plan terms for patients’ problems and goals in the EHR of one large health system to the standardized nursing terminologies (SNTs), NANDA International (NANDA-I), and Nursing Outcomes Classification (NOC).
We extracted local problems and goals used by nurses to document care plans from two hospitals. After removing duplicates, the terms were independently mapped to NANDA-I and NOC by five mappers. Four nurses who regularly use the local vocabulary validated the mapping.
83% of local problem terms were mapped to NANDA-I labels and 93% of local goal terms were mapped to NOC labels. The nurses agreed with 95% of the mapping. Local terms not mapped to labels were mapped to the domains or classes of the respective terminologies.
Mapping local vocabularies used by nurses in EHRs to SNTs is a foundational step to making interoperable nursing data available for research and other secondary purposes in large data trusts. This study is the first phase of a larger project building, for the first time, a pipeline to standardize, harmonize, and integrate nursing care plan data from multiple Florida hospitals into the statewide CDRN OneFlorida+ Clinical Research Network data trust.
To describe the health literacy (HL) levels of hospitalised patients and their relationship with nursing diagnoses (NDs), nursing interventions and nursing measures for clinical risks.
Retrospective ...study.
The study was conducted from December 2020 to December 2021 in an Italian university hospital. From 146 wards, 1067 electronic nursing records were randomly selected. The Single-Item Literacy Screener was used to measure HL. Measures for clinical risks were systematically assessed by nurses using Conley Index score, the Blaylock Risk Assessment Screening Score, Braden score, and the Barthel Index. A univariable linear regression model was used to assess the associations of HL with NDs.
Patients with low HL reported a higher number of NDs, interventions and higher clinical risks. HL can be considered a predictor of complexity of care.
The inclusion of standardised terms in nursing records can describe the complexity of care and facilitate the predictive ability on hospital outcomes.
HL evaluation during the first 24 h. From hospital admission could help to intercept patients at risk of higher complexity of care. These results can guide the development of interventions to minimise needs after discharge.
No patient or public contribution was required to design or undertake this research. Patients contributed only to the data collection.
ABSTRACT Objective To understand the nurses’ perception about the implementation of the nursing process in an Intensive Care Unit. Method Qualitative, exploratory, and descriptive study. Data ...collection took place from February to March/2018, in an Intensive Care Unit of a public hospital in western Santa Catarina, through semi-structured interviews with nine nurses. In the data analysis, it was used the Discourse of the Collective Subject. Results Difficulties and potentialities in the implementation of the nursing process were identified, standing out as a support strategy for the elaboration of study groups for the permanent education of professionals. About the difficulties, it was highlighted the lack of theoretical knowledge about the nursing process and basic disciplines that impact on the clinical evaluation of the patient stands out. Conclusion The implementation proved to be satisfactory under the nurses’ perception, generating an impact on the quality of care, patient safety, nursing records and professional visibility, despite the various barriers identified during its implementation.
RESUMO Objetivo Compreender a percepção dos enfermeiros acerca da implementação do processo de enfermagem em uma Unidade de Terapia Intensiva. Método Estudo qualitativo, exploratório e descritivo. A coleta de dados ocorreu de fevereiro a março/2018, em uma Unidade de Terapia Intensiva de um hospital público do oeste catarinense, por meio de entrevistas semiestruturadas com nove enfermeiros. Na análise dos dados utilizou-se o Discurso do Sujeito Coletivo. Resultados Identificou-se dificuldades e potencialidades na implementação do processo de enfermagem, destacando-se como estratégia de apoio a elaboração de grupos de estudo para educação permanente dos profissionais. Sobre as dificuldades, destacou-se a falta de conhecimento teórico sobre o processo de enfermagem e disciplinas básicas que impactam na avaliação clínica do paciente. Conclusão A implementação se mostrou satisfatório sob a percepção dos enfermeiros, gerando impacto na qualidade da assistência, segurança do paciente, registros de enfermagem e visibilidade profissional, apesar das diversas barreiras identificadas durante a sua implementação.
RESUMEN Objetivo Comprender la percepción de los enfermeros sobre la implementación del proceso de enfermería en una Unidad de Cuidados Intensivos. Método Estudio cualitativo, exploratorio y descriptivo. La recolección de datos se realizó de febrero a marzo/2018, en una Unidad de Cuidados Intensivos de un hospital público en el oeste de Santa Catarina, a través de entrevistas semiestructuradas con nueve enfermeros. En el análisis de datos utilizó el Discurso del Sujeto Colectivo. Resultados Se identificaron dificultades y potencialidades en la implementación del proceso de enfermería, destacándose como una estrategia de apoyo para la elaboración de grupos de estudio para la educación permanente de profesionales. En cuanto a las dificultades, se destacó la falta de conocimiento teórico sobre el proceso de enfermería y las disciplinas básicas que impactan en la evaluación clínica del paciente. Conclusión La implementación demostró ser satisfactoria bajo la percepción de los enfermeros, generando un impacto en la calidad de la atención, la seguridad del paciente, los registros de enfermería y visibilidad profesional, a pesar de las diversas barreras identificadas durante su implementación.
To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health.
A descriptive study conducted through ...interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations.
Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors.
Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.
Background
Documentation tasks comprise a large percentage of nurses’ workloads. Nursing records were partially based on a report from the patient. However, it is not a verbatim transcription of the ...patient's complaints but a type of medical record. Therefore, to reduce the time spent on nursing documentation, it is necessary to assist in the appropriate conversion or citation of patient reports to professional records. However, few studies have been conducted on systems for capturing patient reports in electronic medical records. In addition, there have been no reports on whether such a system reduces the time spent on nursing documentation.
Objective
This study aims to develop a patient self-reporting system that appropriately converts data to nursing records and evaluate its effect on reducing the documenting burden for nurses.
Methods
An electronic medical record–connected questionnaire and a preadmission nursing questionnaire were administered. The questionnaire responses entered by the patients were quoted in the patient profile for inpatient assessment in the nursing system. To clarify its efficacy, this study examined whether the use of the electronic questionnaire system saved the nurses’ time entering the patient profile admitted between August and December 2022. It also surveyed the usability of the electronic questionnaire between April and December 2022.
Results
A total of 3111 (78%) patients reported that they answered the electronic medical questionnaire by themselves. Of them, 2715 (88%) felt it was easy to use and 2604 (85%) were willing to use it again. The electronic questionnaire was used in 1326 of 2425 admission cases (use group). The input time for the patient profile was significantly shorter in the use group than in the no-use group (P<.001). Stratified analyses showed that in the internal medicine wards and in patients with dependent activities of daily living, nurses took 13%-18% (1.3 to 2 minutes) less time to enter patient profiles within the use group (both P<.001), even though there was no difference in the amount of information. By contrast, in the surgical wards and in the patients with independent activities of daily living, there was no difference in the time to entry (P=.50 and P=.20, respectively), but there was a greater amount of information in the use group.
Conclusions
The study developed and implemented a system in which self-reported patient data were captured in the hospital information network and quoted in the nursing system. This system contributes to improving the efficiency of nurses’ task recordings.
Objective: The aim of this study was to plan, develop an devaluate a software to systematize the users’ records of a medical clinic nursery in an universitary hospital. Methods: It was an applied ...study with technological production, throughout three consecutive steps: 1) software planning; 2) software development; 3) software evaluation. Results: It was noticed that the software helps nursing in a better practice, participating in the qualification and in the continuity of assistance. Conclusion: The conclusion was that the software was a successful experience, which the conception was based on the planning, development and evaluation of an information and communication technology in a medical clinic nursery. The technological tool which was developed can help in the working process, throughout there cord of various information.
This study aims to facilitate the creation of quality standardized nursing statements in South Korea's hospitals using algorithmic generation based on the International Classifications of Nursing ...Practice (ICNP) and evaluation through Large Language Models.
We algorithmically generated 15 972 statements related to acute respiratory care using 117 concepts and concept composition models of ICNP. Human reviewers, Generative Pre-trained Transformers 4.0 (GPT-4.0), and Bio_Clinical Bidirectional Encoder Representations from Transformers (BERT) evaluated the generated statements for validity. The evaluation by GPT-4.0 and Bio_ClinicalBERT was conducted with and without contextual information and training.
Of the generated statements, 2207 were deemed valid by expert reviewers. GPT-4.0 showed a zero-shot AUC of 0.857, which aggravated with contextual information. Bio_ClinicalBERT, after training, significantly improved, reaching an AUC of 0.998.
Bio_ClinicalBERT effectively validates auto-generated nursing statements, offering a promising solution to enhance and streamline healthcare documentation processes.
Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, ...its practice and associated factors among Ethiopian nurses are not well investigated.
To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia.
An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses' documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study.
In this study, 372 nurses participated, and 30.4% (95% confidence interval CI: 26%-35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio AOR = 4.16, 95% CI: 2.36-7.33), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: 1.85-6.36), adequacy of documenting sheets (AOR = 2.02, 95% CI: 1.14-3.59), adequacy of time (AOR = 3.85, 95% CI: 2.11-7.05), nurse-to-patient ratio (AOR = 2.78, 95% CI: 1.13-6.84), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: 1.69-7.52) were significantly associated with proper nursing care documentation practices.
Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses' knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.
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