To implement, on health management software, electronic records of the perioperative nursing process and the stages of transoperative and immediate postoperative nursing diagnoses, based on the NANDA ...International taxonomy.
Experience report conducted from the completion of the Plan-Do-Study-Act cycle, which allows improvement planning with a clearer purpose, directing each stage. This study was carried out in a hospital complex in southern Brazil, using the software Tasy/Philips Healthcare.
For the inclusion of nursing diagnoses, three cycles were completed, predictions of expected results were established, and tasks were assigned, defining "who, what, when, and where". The structured model covered seven possibilities of aspects, 92 symptoms and signs to be evaluated, and 15 nursing diagnoses to be used in the transoperative and immediate postoperative periods.
The study allowed implementing electronic records of the perioperative nursing process on health management software, including transoperative and immediate postoperative nursing diagnoses, as well as nursing care.
A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain ...efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.
ABSTRACT Objective: to assess the completeness and tendency of non-completeness of the records of nurses in the care of people with tuberculosis followed up in Primary Health Care. Method: this is a ...descriptive, documentary, retrospective study, with quantitative approach, developed in family health units of a municipality in the state of Paraíba. It took place between July and September 2020. A sample of 190 medical records was delineated, selected by sampling in two stages: proportionality and systematic probabilistics. The collected data were analyzed using the R software, assuming a significance level of 5%. Descriptive statistics, Pareto Chart and trend analysis were used. Results: completeness classification was predominantly “very bad” (76.9%), with a higher percentage of non-completion for the indicators: prejudice (91.1%), preliminary findings (85.2%), absenteeism in consultations (80.8%), family history of tuberculosis (74.7%) and psychosocial aspects. They showed a trend of significant non-completion ascending: lifestyle and conditions of life (p=0.0088) and physical examination (p=0.0352). The only indicator with a trend of significant non-completion descending was Prejudice (p=0.0077). Conclusion: unsatisfactory completeness and a predominantly ascending trend towards non-completion of records was found, indicating points to be prioritized in public health interventions due to their importance in the production of indicators in tuberculosis management in Primary Health Care that can influence decision-making.
RESUMEN Objetivo: evaluar la completitud y la tendencia de incompletitud de los registros de enfermeras en la atención de personas con tuberculosis seguidas en Atención Primaria de Salud. Método: ecisi ecisions s, documental, ecisions s e, con enfoque cuantitativo, desarrollado en las Unidades de Salud de la Familia de un municipio del estado de Paraíba. Tuvo lugar entre julio y septiembre de 2020. Se diseñó una muestra de 190 historias clínicas, seleccionadas por muestreo en dos etapas: proporcional y probabilística sistemática. Los datos recopilados se analizaron utilizando el software R, asumiendo un nivel de significancia del 5%. Se ecisio estadística ecisions s, Diagrama de Pareto y análisis de tendencias. Resultados: hubo una clasificación predominantemente “muy mala” de completitud (76,9%), con un mayor porcentaje de incumplimiento de los indicadores: prejuicio (91,1%), hallazgos diagnósticos (85,2%), absentismo en las citas (80,8%), ecisions s ecisions de tuberculosis (74,7%) y aspectos psicosociales. Mostraron una tendencia de incumplimiento creciente: estilo de vida y condiciones de vida (p=0,0088) y exploración física (p=0,0352). El único indicador con una tendencia a la disminución de los incumplimientos significativos fue Prejuicio (p=0,0077). Conclusión: se encontró una exhaustividad insatisfactoria y una tendencia predominantemente creciente hacia la no cumplimentación de registros, lo que indica puntos a priorizar en las intervenciones de salud pública por su importancia en la producción de indicadores en el control de la tuberculosis en Atención Primaria de Salud que pueden influir en la toma de ecisions.
RESUMO Objetivo: avaliar a completude e a tendência de não completude dos registros de enfermeiros no cuidado às pessoas com tuberculose acompanhadas na Atenção Primária à Saúde. Método: estudo descritivo, documental, retrospectivo, com abordagem quantitativa, desenvolvido nas Unidades de Saúde da Família de um município do estado da Paraíba. Realizou-se entre julho e setembro de 2020. Delineou-se uma amostra de 190 prontuários, selecionados por amostragem em duas etapas: proporcional e probabilística sistemática. Os dados coletados foram analisados mediante o software R, admitindo-se nível de significância de 5%. Empregou-se estatística descritiva, Diagrama de Pareto e análise de tendência. Resultados: observou-se classificação de completude predominantemente “muito ruim” (76,9%), com maior percentual de não completude para os indicadores: preconceito (91,1%), achados propedêuticos (85,2%), absenteísmo em consultas (80,8%), histórico familiar de tuberculose (74,7%) e aspectos psicossociais. Apresentaram tendência de não completude significante crescente: estilo e condições de vida (p=0,0088) e exame físico (p=0,0352). O único indicador com tendência de não completude significativa decrescente foi Preconceito (p=0,0077). Conclusão: constatou-se completude insatisfatória e tendência predominantemente crescente para não completude dos registros, assinalando pontos a serem priorizados nas intervenções de saúde pública em razão de sua importância na produção de indicadores no controle da tuberculose na Atenção Primária à Saúde que podem influenciar a tomada de decisão.
COVID-19 has a range of complications, from no symptoms to severe pneumonia. It can also affect multiple organs including the nervous system. COVID-19 affects the brain, leading to neurological ...symptoms such as delirium. Delirium, a sudden change in consciousness, can increase the risk of death and prolong the hospital stay. However, research on delirium prediction in patients with COVID-19 is insufficient. This study aimed to identify new risk factors that could predict the onset of delirium in patients with COVID-19 using machine learning (ML) applied to nursing records. This retrospective cohort study used natural language processing and ML to develop a model for classifying the nursing records of patients with delirium. We extracted the features of each word from the model and grouped similar words. To evaluate the usefulness of word groups in predicting the occurrence of delirium in patients with COVID-19, we analyzed the temporal changes in the frequency of occurrence of these word groups before and after the onset of delirium. Moreover, the sensitivity, specificity, and odds ratios were calculated. We identified (1) elimination-related behaviors and conditions and (2) abnormal patient behavior and conditions as risk factors for delirium. Group 1 had the highest sensitivity (0.603), whereas group 2 had the highest specificity and odds ratio (0.938 and 6.903, respectively). These results suggest that these parameters may be useful in predicting delirium in these patients. The risk factors for COVID-19-associated delirium identified in this study were more specific but less sensitive than the ICDSC (Intensive Care Delirium Screening Checklist) and CAM-ICU (Confusion Assessment Method for the Intensive Care Unit). However, they are superior to the ICDSC and CAM-ICU because they can predict delirium without medical staff and at no cost.
To reflect on the contributions of representing nursing practice elements in the ISO 18.104:2023 standard.
This is a theoretical study with standard analysis. Categorical structures were described to ...represent nursing practice in terminological systems and contributions identified in the parts of the version were analyzed.
There is innovation in the inclusion of nurse sensitive outcomes, nursing action, nursing diagnosis explanation as an indicator of nursing service demand and complexity of care, representation of concepts through mental maps and suggestion of use of restriction models for nursing actions. It describes that the Nursing Process is constituted by nursing diagnosis, nursing action and nurse sensitive outcomes.
Indicating a nursing diagnosis as an indicator will bring benefits for knowledge production and decision-making. Although care outcomes are not exclusive responses to nursing action, the modifiable attributes of a nursing diagnosis generate knowledge about clinical practice, nursing action effectiveness and subjects of care' health state. There is coherence in understanding the Nursing Process concept evolution.
This study explored nursing care topics for patients with the coronavirus disease 2019 admitted to the wards and intensive care units using International Classification for Nursing Practice-based ...nursing narratives. A total of 256630 nursing statements from 555 adult patients admitted from December 2019 to June 2022 were extracted from the clinical data warehouse. The International Classification for Nursing Practice concepts mapped to 301 unique nursing statements that accounted for the top 90% of all cumulative nursing narratives were used for analysis. The standardized number of nursing statements for each concept was calculated according to the types of nursing care and compared between the two groups. The most documented topics were related to infection; physical symptoms such as sputum, cough, dyspnea, and shivering; and vital signs including blood oxygen saturation and body temperature. Nurses in the intensive care units frequently documented concepts related to the directly monitored and assessed physical signs such as consciousness, pupil reflex, and skin integrity, whereas nurses in wards documented more concepts related to symptoms patients complained. This study showed that the International Classification for Nursing Practice-based nursing records can be used as source of information to identify nursing care for patients with coronavirus disease 19.
This study aimed to analyze the contribution of nursing records to the early identification and management of sepsis in surgical patients at a university hospital.
This is a study with a ...quantitative, retrospective, descriptive, and correlational design. Data collection was performed through hospital information systems in the first semester of 2017 with the approval of the research ethics committee. We included 28 patients who met the inclusion criteria of the study.
The analysis of the content of the records evidenced the development of the first signs of systemic inflammatory response syndrome (SIRS) and organ dysfunction until the fifth day of hospitalization in 19 patients (67.8%). Confirmation or hypothesis of sepsis diagnosis occurred until the 10th day of hospitalization in 15 patients (53.5%). The analysis of the content of the records showed that the first signs of SIRS were predominantly identified in the electronic patient monitoring system in 26 cases (92.9%), whereas the first signs of organ dysfunction were described in the nursing staff records in 24 patients (85.7%).
The results confirm the importance of the quality of nursing records for risk identification, early recognition, and proper management of sepsis in surgical patients, aiming at achieving greater effectiveness in the management of healthcare processes.
•The development of the first signs of SIRS and organ dysfunction occurred until the fifth day of hospitalization.•Confirmation or hypothesis of sepsis diagnosis occurred until the 10th day of hospitalization.•The first signs of SIRS were predominantly identified in the electronic patient monitoring system.•The first signs of organ dysfunction were described in the nursing staff records.•The quality of nursing records is crucial to early recognising patients with sepsis.
In literature it is reported that accurate nursing documentation improves patients' outcomes but nursing planning data is seldom available. The accuracy of nursing documentation in hospitals has been ...assessed in many healthcare settings through the detection of three key elements of nursing decision-making: diagnoses, interventions and outcomes. However, studies conducted in Italy are scant and none of them have been conducted in Lombardy Region.
the aim of this study is to assess the accuracy of nursing documentation in six hospitals. Accuracy in documentation's compilation was sought, as well as the three essential elements expected in the nursing decision-making process: diagnoses, interventions and outcomes.
a multicentre retrospective observational study was conducted on a sample of 430 computerized and paper-based nursing records in surgical and medical areas. D-Catch instrument was used to evaluate documentation's accuracy. This instrument is divided into six sections, with scores ranging from one to four: a higher score corresponds to a greater accuracy of the documentation. The six sections assess whether the documentation structure and the assessment are accurate, the presence of a nursing diagnosis, the accuracy of interventions and assessments and documentation's clarity and legibility.
it emerged that in the six hospitals there is a structured and personalized nursing documentation. From the 430 nursing documentations, a total of 623 nursing diagnoses were observed. Diagnoses reached an average score of 2.5, with significant differences between surgical and medical areas and between computerized and paper documentations. Interventions also showed significant differences between surgical and medical areas, and between computerized and paper documentation, with an average score of 2.04. The outcomes received the lowest scores with an average of 1.75.
the specific nursing data that would make the care process evident are hardly visible and, despite the nursing records of the six hospitals being oriented by a conceptual model, there is no shared terminology that helps nurses to describe univocally the care process. The introduction of a standardized nursing language and an integrated computerized medical record could help to improve the accuracy of the documentation.
Abstract
Background
Demographic trends show an increasing number of elderly people and thus a growing need for palliative care (PC). Such care is increasingly being provided by long-term care (LTC) ...facilities. The present study aimed at exploring PC indicators of residents at LTC facilities belonging to a non-profit provider in Lower Saxony, Germany, in order to identify potential improvements.
Methods
A descriptive cross-sectional study was conducted, drawing on routine nursing chart data. Structural data from 16 participating LTC facilities and the care data of all residents who died in 2019 (
N
= 471) were collected anonymously between March and May 2020. Based on key literature on quality indicators of PC in LTC facilities in Germany, a structured survey was developed by a multidisciplinary research team. The descriptive, comparative and inferential data analysis was conducted using the SPSS software package.
Results
In total, the complete records of 363 (77%) residents who died in the participating LTC facilities in 2019 were retrieved. The records reflected that 45% of the residents had been hospitalized at least once during the last 6 months of their lives, and 19% had died in hospital. Advance care planning (ACP) consultation was offered to 168 (46%) residents, and 64 (38%) declined this offer. A written advance directive was available for 47% of the residents. A specialized PC team and hospice service volunteers were involved in caring for 6% and 14% of the residents, respectively. Cancer patients received support from external services significantly more frequently (
p
< .001) than did non-cancer patients. Differences emerged in the distribution of PC indicators between LTC facilities. Facilities that have more PC trained staff offered more ACP, supported by more specialized PC teams and hospice services, and had fewer hospitalizations. In addition, more volunteer hospice services were offered in urban facilities.
Conclusions
Overall, a rather positive picture of PC in participating LTC facilities in Germany emerged, although there were differences in the expression of certain indicators between facilities. ACP consultation, volunteer hospice services, and hospital admissions appeared to be superior in LTC facilities with more trained PC staff. Therefore, PC training for staff should be further promoted.
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