Nursing Documentation Research Articles

Model-informed precision dosing of vancomycin in clinical practice: an intervention development study.

Current guidelines recommend dosing vancomycin based on the area under the concentration time curve (AUC) to maximise efficacy and minimise the risk of nephrotoxicity. The preferred approach to AUC-guided therapy is to apply model-informed precision dosing (MIPD). However, the adoption in clinical practice has been slow. We aimed to develop an intervention, including a standardised MIPD workflow and an implementation plan for vancomycin AUC-guided dosing, in a Swedish tertiary hospital. The intervention was developed in a framework-guided process. The design phase included stakeholder feedback (nurses, pharmacists, physicians), local data collection and feasibility testing of intervention components with parallel consideration of implementation aspects. The hypothesised relationships between the different components, implementation strategies and the mechanism of action resulting in expected outcomes were represented by a logic model. The final intervention consisted of a workflow for MIPD, with defined roles and responsibilities, as well as processes for data and information transfer. Details were provided in supportive documents; an instruction on therapeutic drug monitoring (TDM) sampling and documentation for nurses, and a detailed dosing software instruction for MIPD consultants and clinical pharmacists. Activities to facilitate implementation included the development of a local clinical routine for vancomycin dosing, staff training and recurring MIPD rounds. An intervention for MIPD, with an implementation plan for AUC-guided dosing of vancomycin, was developed for a tertiary hospital setting. The process can be used as guidance for other institutions with similar context wishing to initiate MIPD.

Nurse-led framework to improve the safety and quality of residential aged care (HIRAID® Aged Care): protocol for a stepped-wedge cluster randomised controlled trial

BackgroundThe health issues experienced by older people can often be severe and complex, and an increasing number are using residential aged care services to meet their care needs. High-quality nursing care is fundamental to the health and safety of aged care residents and is contingent on nurses’ accurate assessment, informed decision-making, and delivery of timely interventions. However, the role of the aged care nurse is often challenging, impeded by factors such as understaffing, high workloads, and a lack of access to clinical infrastructure and resources. When these challenges mount, residents are put at greater risk of adverse outcomes, such as avoidable clinical deterioration and hospital transfers. This study describes the adaptation and implementation of the emergency nursing framework, HIRAID® (History including Infection risk, Red Flags, Assessment, Interventions, Diagnostics, reassessment, communication and plan)—a tool to assist nurses’ assessment, decision-making and care in residential aged care.MethodsThe HIRAID® framework will be adapted for residential aged care using a real-time Delphi and panel of aged care and nursing experts. The co-designed HIRAID® Aged Care framework will be trialled in 23 residential aged care homes in Sydney, Australia, in a modified stepped-wedge cluster randomised controlled trial design. All homes will be randomised into one of four clusters. Outcomes of interest include the rate of clinical deterioration events resulting from nurses’ actions, the rate of hospital transfers determined to be inappropriate, performance against the national mandatory aged care quality indicators, resident satisfaction with care, nurse and medical staff satisfaction with communication, and the quality of nursing documentation. These outcomes will be evaluated using a combination of qualitative and quantitative analysis of routinely collected resident data, expert assessments of facility documentation events against validated criteria, and pre- and post-intervention surveys of residents, family carers, nurses, and medical staff.DiscussionThis protocol describes a pragmatic trial that aims to translate an evidence-based framework from the emergency care context into residential aged care. The adapted HIRAID® Aged Care framework will be the first of its kind to standardise and guide holistic nursing assessment, decision-making, and documentation in residential aged care in Australia.Ethics and disseminationThis research has been approved by the Western Sydney Local Health District Human Research Ethics Committee: 2023/ETH00523. A waiver of consent has been approved to access resident health data and nursing documentation at each participating site.Trial registrationAustralian and New Zealand Clinical Trial Registry, ACTRN12623000481673. Registered 12 May 2023.Protocol versionVersion 1.0 6 February 2024.

Nurses' experiences using electronic medical record (EMR): A systematic review

Background: The evolution of information and communication technology has led to significant changes in nursing care and the health care system, particularly through the use of Electronic Medical Records (EMR). This literature review focuses on the pivotal role of nurses in the development and implementation of EMR for the documentation of nursing care. Purpose: To investigate nurses' experiences with electronic medical records (EMR) for documenting nursing care. Method: A systematic review approach in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were sourced from online databases such as PubMed, Google Scholar, Garuda, and Science and Technology Index (SINTA). The review was organized according to the PICOS framework. In this article, the PICOS criteria were defined as follows: P: Nurse and health worker, I: Nursing documentation uses electronic medical records, C: Explains the influence, impact of electronic documentation, O: Efficiency, quality of health care and safety of patient care, S: qualitative research methods. The keywords used in the search included “documentation of nursing”, “electronic medical record” and “nurse performance”. Articles were selected based on specific inclusion criteria: publication within the last five years (2019-2024), English language, use of qualitative research methodology, the nurse uses electronic medical records, and with full-text availability. Results: The literature review found that most nurses felt a sense of ease and efficiency in filling out documentation, higher data accuracy, increased work productivity, and ease in identifying patient data to carry out nursing diagnoses regarding patient care, thereby underscoring the integral role of nurses in the development and use of EMR. Conclusion: Computer-based nursing care documentation provides various conveniences and helps nurses deliver their care. Thus, considering the use of EMR in nursing documentation may increase the quality of care.

Improving Family-Centered Rounds With a Nursing Checklist in the Electronic Health Care Record.

Family-centered rounds (FCR) is the standard for pediatric communication, but community pediatric hospital medicine services may face barriers in implementation, including offering FCR to families with a language preference other than English (LOE) versus those with an English preference (EP). The goal of our quality improvement project was to increase FCR from 33% to 80% over 1 year. Interventions included an FCR checklist integrated into the electronic healthcare record (EHR-FCR checklist), staff education, visual prompts, and interpreters. Our primary outcome measure was weekly % FCR. Our main process measure was weekly % nursing documentation. To address language inclusion, we compared FCR encounters for families with LOE versus EP. The use of the checklist without interventions was assessed during the sustain period. Control charts were used to analyze measures. Fisher's exact test was used to compare FCR for families with LOE versus EP. FCR increased to 81% during the intervention period and then decreased to 73% during the sustain period. Nursing documentation increased to 93% with the EHR-FCR checklist implemented as a flowsheet. There was no statistical difference in the proportion of families with LOE versus EP who participated in FCR (84% versus 81%, P = .38) during the intervention period; a statistically higher proportion of families with LOE participated in FCR during the sustain period (87% vs 72%, P <.01). We increased documented FCR on our community pediatric hospital medicine service, including FCR for families with LOE, by implementing a nursing-completed EHR-FCR checklist supported by staff education, visual prompts, and interpreters.

Exploring Natural Language Processing through an Exemplar Using YouTube.

There has been a growing emphasis on data across various health-related fields, not just in nursing research, due to the increasing volume of unstructured data in electronic health records (EHRs). Natural Language Processing (NLP) provides a solution by transforming this unstructured data into structured formats, thereby facilitating valuable insights. This methodology paper explores the application of NLP in nursing, using an exemplar case study that analyzes YouTube data to investigate social phenomena among adults living alone. The methodology involves five steps: accessing data through YouTube's API, data cleaning, preprocessing (tokenization, sentence segmentation, linguistic normalization), sentiment analysis using Python, and topic modeling. This study serves as a comprehensive guide for integrating NLP into nursing research, supplemented with digital content demonstrating each step. For successful implementation, nursing researchers must grasp the fundamental concepts and processes of NLP. The potential of NLP in nursing is significant, particularly in utilizing unstructured textual data from nursing documentation and social media. Its benefits include streamlining nursing documentation, enhancing patient communication, and improving data analysis.

Navigating the Complexities of Nursing Documentation When Patients Have Access to the Content: A Qualitative Study.

To explore how Danish registered nurses (RNs) in hospitals experience documenting nursing care in electronic patient records when the content is accessible to patients. In a qualitative research design, data were generated in six focus groups conducted in late 2022 and early 2023, comprising 31 RNs employed in inpatient wards at a university hospital in Denmark. Subsequently, qualitative content analysis was applied to the gathered data. The findings include three themes: (1) weighing one's words, (2) building trust or triggering conflicts and (3) risking loss of knowledge. Together, these three themes illustrate the complexities that RNs navigate when patients have access to the content of nursing documentation. Patients' access to nursing documentation requires RNs to navigate a complex interplay of factors, including awareness of language-use, influence on the nurse-patient-relative relationships, and the risk of losing essential knowledge. Therefore, although patients' access to nursing documentation can induce a positive change in terms of strengthening the professional focus on documentation, it can also result in changes in documentation practices in ways that may compromise nursing documentation as a working tool. The findings emphasize an urgent need to explore and discuss how sensitive nursing observations can be shared in a safe and appropriate way when patients have access to the documentation. Furthermore, to prevent misunderstandings and conflicts with patients, it is essential to focus on and prioritize patient involvement in nursing documentation. RNs navigate complex practices when patients have direct online access to nursing documentation content. It is crucial to clarify which content nursing documentation should entail and how sensitive nursing observations can be shared in a safe and appropriate way. The COREQ checklist was used for reporting.

Under Pressure: An Audit of Pressure Injury Documentation in Hospitalised Older Adults

Abstract Background Pressure injuries are common in hospitalised older adults. They are associated with adverse outcomes including reduced quality of life, pain, insomnia, mood disturbance and secondary infection. They can negatively affect mobility and prolong hospital stay with financial cost to the health service. Pressure injuries represent a geriatric syndrome with multifactorial risk factors, requiring multidisciplinary communication to optimise management. Methods Retrospective audit over three months in adults over 65 years, admitted to a geriatric rehabilitation ward. Audit aims were (1) Review medical staff pressure injury written documentation and (2) Review medical staff written communication and handover regarding pressure injuries. Data were gathered from medical records including written notes and discharge letters. Results Twenty-six patients had thirty-six individual pressure injuries. The mean age was 83 years, 53% female and 47% male. Total length of stay mean was 50 days (range 16 – 147 days). Thirty-nine percent of pressure injuries were stage 1, 42% stage 2, 3% stage 3, 6% suspected deep and 11% unstageable. Documentation in the medical admission occurred in 21% and medical notes in 33%. Documentation in multidisciplinary team (MDT) meetings occurred in 17% and discharge letters in 22%. The mean time between nursing pressure injury identification, and medical and MDT documentation was 17 and 16 days respectively. Conclusion Medical team written documentation of pressure injuries was low. Only one-fifth to one-third of pressure injuries were recorded. Although pressure injuries benefit from multidisciplinary management, they were documented in MDT meetings in under one-fifth of cases. Delays of more than two weeks between nursing and medical documentation occurs. Improving documentation and communication between the MDT can optimise pressure injury management, highlighting the need for ongoing medical education and more effective documentation processes.

The Effect of Implementing 3S (SIND, SINO, SINI)-based Orthopedic Nursing Care Instrument in Improving Nursing Service Quality and Patient Safety in Indonesia Hospital

Along with the increasing of orthopedic disorders incidence, the provision of orthopedic nursing care in Indonesia is also increasing. The Indonesian National Nurses Association (INNA) has published nursing care standards as a reference for nurses in providing nursing care and standardizing nursing care terminologies. Standard-based orthopedic nursing care instruments have been developed, but their effectiveness has not been investigated in improving the quality of nursing services and patient safety. This study aimed to identify the effect of the application of 3S-based Orthopedic Nursing Care (3S-ONC) on the quality of nursing services and patient safety. Descriptive quantitative analysis using a quasi-experimental method with a pretest and posttest with control group design, involving 106 respondents (53 control, 53 intervention), recruited by purposive sampling technique. In the intervention group, nurses provided nursing care by applying the 3S-based Orthopedic Nursing Care (3S-ONC) instrument. The study showed that in both groups, most of the nurses were in the early adult category, dominated by female sex and most of them had professional education level. There were significant differences in the quality of nursing services (p 0.046; α 0.05) and patient safety (p 0.000; α 0.05) between the intervention group and the control group after the application of the 3S-ONC instrument. The 3S-ONC instrument can improve the quality of nursing services and the safety of patients with orthopedic disorders in hospitals.The 3S-ONC instrument can be considered for the development of a paper-based or computer-based nursing care documentation system to further improve the quality of nursing services and patient safety in healthcare facilities, especially in hospital.

Electronic nursing documentation for patient safety, quality of nursing care, and documentation: a systematic review .

To evaluate the impact of electronic nursing documentation on patient safety, quality of nursing care and documentation. The systematic review was conducted in December 2022, and comprised a comprehensive search on Scopus, ScienceDirect, ProQuest, PubMed, Cumulative Index to Nursing and Allied Health Literature, Sage Journals and Google Scholar databases for English-language human studies published between 2018 and 2022. The key words used in the search included "Nursing", "care", "documentation", "record", "electronic", "process" and "health services". The risk of bias was assessed using Strengthening the Reporting of Observational Studies in Epidemiology tool. Of the 469 items initially identified, 15(3.2%) were analysed in detail, indicating a positive influence of electronic nursing documentation on patient safety, care quality, and documentation. However, shortcomings were observed in the development of electronic nursing documentation for optimal effectiveness. Electronic nursing documentation significantly enhanced patient safety, care quality and documentation. To facilitate its integration into clinical settings, a standardised and logically structured electronic nursing documentation system is essential.

The National Transformation of Nursing Documentation in Wales.

In response to findings indicating poor standardisation and quality in nursing documentation, NHS Wales embarked on a transformative journey with the National Electronic Nursing Documentation Programme in 2014. Evolving into the Welsh Nursing Care Record (WNCR) by 2019, this initiative sought to streamline practices and enhance accuracy, compliance, and efficiency through a standardised digital platform. The case study explores the comprehensive project design, emphasising evidence-based practices, governance processes and the introduction of National Nursing Informatics roles. Accomplished from April 2021 to September 2023, the WNCR implementation achieved a 79% roll out across eligible wards, marked by strategic investments, robust training, and phased deployment. Evaluations to date show positive impacts on key performance indicators, exemplified by a 9-minute time saving per patient. Lessons learned noted the significance of user engagement, cultural transformation, and ongoing staff development, paving the way for future strategies including nationwide implementation, benefits realisation, and data visualisation initiatives.

Capturing patient mobility levels in the hospital: An examination of nursing charting and behavioural mapping.

Our study aimed to (1) validate the accuracy of nursing mobility documentation and (2) identify the most effective timings for behavioural mapping. We monitored the mobility of 55 inpatients using behavioural mapping throughout a nursing day shift, comparing the observed mobility levels with the nursing charting in the electronic health record during the same period. Our results showed a high level of agreement between nursing records and observed mobility, with improved accuracy observed particularly when documentation was at 12 PM or later. Behavioural mapping observations revealed that the most effective timeframe to observe the highest levels of patient mobility was between 10 AM AND 2 PM. To truly understand patient mobility, comparing nursing charting with methods like behavioural mapping is beneficial. This comparison helps evaluate how well nursing records reflect actual patient mobility and offers insights into the best times for charting to capture peak mobility. While behavioural mapping is a valuable tool for auditing patient mobility, its high resource demands limit its regular use. Thus, determining the most effective times and durations for observations is key for practical implementation in hospital mobility audits. Nurses are pivotal in ensuring patient mobility in hospitals, an essential element of quality care. Their role involves safely mobilizing patients and accurately charting their mobility levels during each shift. For nursing practice, this research underscores that nurse charting can accurately reflect patient mobility, and highlights that recording the patient's highest level of mobility later in the shift offers a more precise representation of their actual mobility. Strobe. No Patient or Public Contribution.

Leveraging Nursing Assessment for Early Identification of Post Operative Gastrointestinal Dysfunction (POGD) in Patients Undergoing Colorectal Surgery.

Background: Postoperative gastrointestinal dysfunction (POGD) remains a common morbidity after gastrointestinal surgery. POGD is associated with delayed hospital recovery, increased length of stay, poor patient satisfaction and experience, and increased economic hardship. The I-FEED scoring system was created by a group of experts to address the lack of a consistent objective definition of POGD. However, the I-FEED tool needs clinical validation before it can be adopted into clinical practice. The scope of this phase 1 Quality Improvement initiative involves the feasibility of implementing percussion into the nursing workflow without additional burden. Methods: All gastrointestinal/colorectal surgical unit registered nurses underwent comprehensive training in abdominal percussion. This involved understanding the technique, its application in postoperative gastrointestinal dysfunction assessment, and its integration into the existing nursing documentation in the Electronic Health Record (EHR). After six months of education and practice, a six-question survey was sent to all inpatient GI surgical unit nurses about incorporating the percussion assessment into their routine workflow and documentation. Results: Responses were received from 91% of day-shift nurses and 76% of night-shift registered nurses. Overall, 95% of the nurses were confident in completing the abdominal percussion during their daily assessment. Conclusion: Nurses' effective use of the I-FEED tool may help improve patient outcomes after surgery. The tool could also be an effective instrument for the early identification of postoperative gastrointestinal dysfunction (POGD) in surgical patients.

A Scalable and Extensible Logical Data Model of Electronic Health Record Audit Logs for Temporal Data Mining (RNteract): Model Conceptualization and Formulation.

Increased workload, including workload related to electronic health record (EHR) documentation, is reported as a main contributor to nurse burnout and adversely affects patient safety and nurse satisfaction. Traditional methods for workload analysis are either administrative measures (such as the nurse-patient ratio) that do not represent actual nursing care or are subjective and limited to snapshots of care (eg, time-motion studies). Observing care and testing workflow changes in real time can be obstructive to clinical care. An examination of EHR interactions using EHR audit logs could provide a scalable, unobtrusive way to quantify the nursing workload, at least to the extent that nursing work is represented in EHR documentation. EHR audit logs are extremely complex; however, simple analytical methods cannot discover complex temporal patterns, requiring use of state-of-the-art temporal data-mining approaches. To effectively use these approaches, it is necessary to structure the raw audit logs into a consistent and scalable logical data model that can be consumed by machine learning (ML) algorithms. We aimed to conceptualize a logical data model for nurse-EHR interactions that would support the future development of temporal ML models based on EHR audit log data. We conducted a preliminary review of EHR audit logs to understand the types of nursing-specific data captured. Using concepts derived from the literature and our previous experience studying temporal patterns in biomedical data, we formulated a logical data model that can describe nurse-EHR interactions, the nurse-intrinsic and situational characteristics that may influence those interactions, and outcomes of relevance to the nursing workload in a scalable and extensible manner. We describe the data structure and concepts from EHR audit log data associated with nursing workload as a logical data model named RNteract. We conceptually demonstrate how using this logical data model could support temporal unsupervised ML and state-of-the-art artificial intelligence (AI) methods for predictive modeling. The RNteract logical data model appears capable of supporting a variety of AI-based systems and should be generalizable to any type of EHR system or health care setting. Quantitatively identifying and analyzing temporal patterns of nurse-EHR interactions is foundational for developing interventions that support the nursing documentation workload and address nurse burnout.

Multisite Pragmatic Cluster-Randomized Controlled Trial of the CONCERN Early Warning System.

Late predictions of hospitalized patient deterioration, resulting from early warning systems (EWS) with limited data sources and/or a care team's lack of shared situational awareness, contribute to delays in clinical interventions. The COmmunicating Narrative Concerns Entered by RNs (CONCERN) Early Warning System (EWS) uses real-time nursing surveillance documentation patterns in its machine learning algorithm to identify patients' deterioration risk up to 42 hours earlier than other EWSs. To test our a priori hypothesis that patients with care teams informed by the CONCERN EWS intervention have a lower mortality rate and shorter length of stay (LOS) than the patients with teams not informed by CONCERN EWS. One-year multisite, pragmatic controlled clinical trial with cluster-randomization of acute and intensive care units to intervention or usual-care groups. Two large U.S. health systems. Adult patients admitted to acute and intensive care units, excluding those on hospice/palliative/comfort care, or with Do Not Resuscitate/Do Not Intubate orders. The CONCERN EWS intervention calculates patient deterioration risk based on nurses' concern levels measured by surveillance documentation patterns, and it displays the categorical risk score (low, increased, high) in the electronic health record (EHR) for care team members. Primary outcomes: in-hospital mortality, LOS; survival analysis was used. Secondary outcomes: cardiopulmonary arrest, sepsis, unanticipated ICU transfers, 30-day hospital readmission. A total of 60 893 hospital encounters (33 024 intervention and 27 869 usual-care) were included. Both groups had similar patient age, race, ethnicity, and illness severity distributions. Patients in the intervention group had a 35.6% decreased risk of death (adjusted hazard ratio [HR], 0.644; 95% confidence interval [CI], 0.532-0.778; P<.0001), 11.2% decreased LOS (adjusted incidence rate ratio, 0.914; 95% CI, 0.902-0.926; P<.0001), 7.5% decreased risk of sepsis (adjusted HR, 0.925; 95% CI, 0.861-0.993; P=.0317), and 24.9% increased risk of unanticipated ICU transfer (adjusted HR, 1.249; 95% CI, 1.093-1.426; P=.0011) compared with patients in the usual-care group. A hospital-wide EWS based on nursing surveillance patterns decreased in-hospital mortality, sepsis, and LOS when integrated into the care team's EHR workflow. ClinicalTrials.gov Identifier: NCT03911687.

Dyspnea management in patients with pneumonia and coronary artery disease: A case study

Background: Cardiovascular disease, particularly Coronary Artery Disease (CAD), is strongly linked to pneumonia. Patients suffering from both pneumonia and CAD frequently experience dyspnea as a symptom. Dyspnea, caused by both conditions, can significantly impact the patient's quality of life. Consequently, it is crucial to address and manage dyspnea in individuals with pneumonia and CAD. Purpose: To provide a thorough overview of managing dyspnea in patients with pneumonia and CAD in public hospitals in West Java, Indonesia. Method: Employing a case study methodology using a nursing care approach, encompassing nursing assessment, data analysis, diagnosis, intervention, implementation, evaluation, and documentation. The assessment indicated that the patient experienced shortness of breath, with a blood pressure of 145/86 mmHg, a respiratory rate of 24 breaths per minute, a pulse rate of 95 beats per minute, and an oxygen saturation level of 88%. The patient received 5 liters per minute of oxygen via a nasal cannula, and their body temperature measured 36.4ºC. Results: In this case study, dyspnea management involved positioning the patient, administering oxygen therapy in stages, and providing pharmacological treatments, including diuretics and antibiotics. Additional therapies included respiratory muscle training and effective cough exercises. These interventions successfully reduced the patient's respiratory rate to 18 breaths per minute and increased their oxygen saturation to 97% with a nasal cannula. Additionally, the patient's Medical Research Council (MRC) dyspnea scale score decreased to 1 out of 5. Conclusion: Nursing care management that includes positioning the patient in a semi-Fowler's position while resting and a Fowler's position when awake, administering oxygen therapy in stages, providing pharmacological treatments such as diuretics and antibiotics, and conducting respiratory muscle training, can lower the breathing rate and alleviate symptoms of shortness of breath in patients with pneumonia and coronary artery disease.

Acupressure, a promising intervention for fatigue, within the European nursing care pathways (ENP): An integrative review.

The aim of this study is to test whether acupressure for patients with fatigue is an efficient nursing intervention and if it can be implemented into the European nursing care pathways (ENP) nursing classification system. Previously, interventions for acupressure were included nonspecifically in ENP and therefore were not available for standardized nursing documentation in an electronic health record (EHR). Acupressure is a nursing intervention that is increasingly used in specific settings. ENP is a nursing classification system that provides evidence-based nursing interventions for nursing diagnoses. A systematic international literature search was conducted from May 2021 to December 2021. An iterative, hierarchical search process according to the 6S evidence pyramid was chosen. The results were reported following the PRISMA statement. Findings of 49 included publications that studied a total of 1,716 patients indicate that certain acupressure points may be efficient in treating fatigue. Acupressure is a useful nursing intervention and can really help patients experiencing fatigue. It is illustrated how the findings have been implemented in the development of ENP nursing interventions to document acupressure. The acupressure points most frequently used on the ear with positive effects in improving fatigue are Shen Men, liver, spleen, subcortex, endocrine, heart, and sympathetic, while the most common points on the body are ST 36, SP 6, LI 4, HT 7, KID 1, Ex-HN 3, Ex-HN, and KID 3. In the future, nurses will be able to use ENP to quickly and easily document acupressure interventions for fatigue in the EHR. In the EHR, the documentation of the nursing process with ENP could help to promote research into evidence-based approaches to fatigue by generating mass data on the different concepts of acupressure, which could lead to a clearer determination of the evidence and contribute to the safety of care and patients.

Using interoperable nursing care data to improve outcomes for multiple traumas patients with Impaired Physical Mobility.

To demonstrate how interoperable nursing care data can be used by nurses to create a more holistic understanding of the healthcare needs of multiple traumas patients with Impaired Physical Mobility. By proposing and validating linkages for the nursing diagnosis of Impaired Physical Mobility in multiple trauma patients by mapping to the Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) equivalent terms using free-text nursing documentation. A descriptive cross-sectional design, combining quantitative analysis of interoperable data sets and the Kappa's coefficient score with qualitative insights from cross-mapping methodology and nursing professionals' consensus. Cross-mapping methodology was conducted in a Brazilian Level 1 Trauma Center using de-identified records of adult patients with a confirmed medical diagnosis of multiple traumas and Impaired Physical Mobility (a nursing diagnosis). The hospital nursing free-text records were mapped to NANDA-I, NIC, NOC and NNN linkages were identified. The data records were retrieved for admissions from September to October 2020 and involved medical and nursing records. Three expert nurses evaluated the cross-mapping and linkage results using a 4-point Likert-type scale and Kappa's coefficient. The de-identified records of 44 patients were evaluated and then were mapped to three NOCs related to nurses care planning: (0001) Endurance; (0204) Immobility Consequences: Physiological, and (0208) Mobility and 13 interventions and 32 interrelated activities: (6486) Environmental Management: Safety; (0840) Positioning; (3200) Aspiration Precautions; (1400) Pain Management; (0940) Traction/Immobilization Care; (3540) Pressure Ulcer Prevention; (3584) Skincare: Topical Treatment; (1100) Nutrition Management; (3660) Wound Care; (1804) Self-Care Assistance: Toileting; (1801) Self-Care Assistance: Bathing/Hygiene; (4130) Fluid Monitoring; and (4200) Intravenous Therapy. The final version of the constructed NNN Linkages identified 37 NOCs and 41 NICs. These valid NNN linkages for patients with multiple traumas can serve as a valuable resource that enables nurses, who face multiple time constraints, to make informed decisions efficiently. This approach of using evidence-based linkages like the one developed in this research holds high potential for improving patient's safety and outcomes. In this study, there was no direct involvement of patients, service users, caregivers or public members in the design, conduct, analysis and interpretation of data or preparation of the manuscript. The study focused solely on analysing existing de-identified medical and nursing records to propose and validate linkages for nursing diagnoses.

Validity of inpatient electronic health record-based measures of oxygen-related therapy in the United States: Lessons applicable for studying COVID-19 endpoints.

During the COVID-19 pandemic, inpatient electronic health records (EHRs) have been used to conduct public health surveillance and assess treatments and outcomes. Invasive mechanical ventilation (MV) and supplemental oxygen (O2) use are markers of severe illness in hospitalized COVID-19 patients. In a large US system (n = 142 hospitals), we assessed documentation of MV and O2 use during COVID-19 hospitalization in administrative data versus nursing documentation. We identified 319 553 adult hospitalizations with a COVID-19 diagnosis, February 2020-October 2022, and extracted coded, administrative data for MV or O2. Separately, we developed classification rules for MV or O2 supplementation from semi-structured nursing documentation. We assessed MV and O2 supplementation in administrative data versus nursing documentation and calculated ordinal endpoints of decreasing COVID-19 disease severity. Nursing documentation was considered the gold standard in sensitivity and positive predictive value (PPV) analyses. In nursing documentation, the prevalence of MV and O2 supplementation among COVID-19 hospitalizations was 14% and 75%, respectively. The sensitivity of administrative data was 83% for MV and 41% for O2, with both PPVs above 91%. Concordance between sources was 97% for MV (κ = 0.85), and 54% for O2 (κ = 0.21). For ordinal endpoints, administrative data accurately identified intensive care and MV but underestimated hospitalizations with O2 requirements (42% vs. 18%). In comparison to nursing documentation, administrative data under-ascertained O2 supplementation but accurately estimated severe endpoints such as MV. Nursing documentation improved ascertainment of O2 among COVID-19 hospitalizations and can capture oxygen requirements in adults hospitalized with COVID-19 or other respiratory illnesses.

Dampak Dokumentasi Elektronik terhadap Implementasi, Manfaat dan Hambatan pada Pelayanan Home Care

This study aims to determine the role of digitization in the documentation of nursing care for community nurses in home care services. Involving aspects of implementation, benefits and barriers in using electronic nursing documentation. The method used was using electronic databases such as Ebsco, Scopus, Proquest, and PubMed published between 2020-2023. Based on the initial search, there were 8 relevant articles out of 320 articles found. The results showed that the implementation of electronic nursing care documentation has a positive impact on patients, nurses and health services. However, several obstacles were found, namely the skills and knowledge of nurses on electronic documentation are still lacking, so training is needed. Internet network constraints are also very influential, especially in rural areas. In conclusion, there is a gap between the need for internet and internet distribution which is a challenge for the government in developing digitalization in the health sector and improving nurses' skills in electronic documentation. Keywords: Electronic Documentation, Barriers, Benefits

Analisis Penerapan Manajemen Dokumentasi Asuhan Keperawatan Elektronik

Electronic nursing care documentation plays an important role in maintaining patient safety. Electronic documentation can identify the potential for increasing efficiency and effectiveness in providing nursing care. The purpose of this article is to determine the application of electronic nursing care documentation management. This research is a case study obtained when students carried out the Nursing Management Stage practice at one of the hospitals in Bogor City from 16 October - 10 November 2023. Data collection was carried out through several processes which included management review of electronic documentation based on 5M, SWOT analysis and formulation and problem priorities using the criteria of magnitude, severity, manageability, nursing concern, affordability which are assessed with a score of 1 – 5. The vision of room X is electronic-based so that effective nurses need time to adapt to technology to carry out electronic-based nursing documentation. The conclusion is that documentation of nursing care plays a crucial role as an important process for recording patient care information.