Nursing Documentation Research Articles

Physicians and nurses documentation practice at the University of Gondar Teaching Hospital, Northwest Ethiopia

Introductionquality medical documentation helps to explain the services provided to a particular person and enhance the exchange of information between health care providers. The objective of this study was to assess the documentation practice of physicians and nurses in a teaching hospital, University of Gondar, Ethiopia. MethodsA descriptive cross-sectional study was carried out with a total of 284 respondents who were selected with a stratified simple random sampling from January 8 to January 23, 2020. Data were collected using self-administered questionnaire. Data were entered using epi info version 7 and analyzed using SPSS version 20. Descriptive statistics was performed and then presented using tables. Respondent characteristics were summarized using frequency and percentages. A Chi-square test was used to investigate associations between the independent and outcome variables. ResultLess than half of the respondents (46.8%, n = 133) had a good medical documentation practice. Chi-squared test of association revealed no significant association on documentation practice with gender (χ2 = 1.48, df = 2 and p = 0.477) and respondent's profession (χ2 = 3.50, df = 1 and p = 0.065). Attitude (χ2 = 6.12, df = 1 and p = 0.013) and knowledge (χ2 = 57.6, df = 1 and p = 0.000) had association with documentation practice. Conclusionand recommendation: As a conclusion, documentation practice of the respondents was inadequate. The working setting, supervision and feedback, standardized documentation sheets, in-service training, educational status, attitude, and knowledge of respondents to medical documentation had an association. It is advisable to perform trainings regarding standardized documentation sheets to enhance better documentation practice by health professions.

CORRELATION OF THE HEADROOM SUPERVISION AND THE ELECTRONIC NURSING DOCUMENTATION METHOD IN THE ERA OF COVID-19

The application of electronic nursing documentation makes it difficult for nurses to adapt to the system. Supervision carried out by the head of the room can affect the quality of electronic nursing documentation. The purpose of this study was to identify the correlation between the supervision of the head of the room and the implementation of nursing care using the Electronic Nursing Documentation. This study uses a descriptive correlation research design using a cross sectional approach. The sampling technique used was purposive sampling with a total sample of 129 nurses. Collecting data using a questionnaire and analyzed using the Chi-Square test. The results of statistical tests showed that there was a significant relationship supervision (p=0.000) with electronic nursing documentation. The recommendation of this study is that hospital management is expected to be able to periodically supervise electronic nursing documentation, even in the current state of the Covid-19 pandemic.Keywords: Electronic Nursing Documentation, Nurse, Supervision

Using telemedicine in nursing homes during the COVID-19 pandemic: A multi-perspective view on the implementation process.

AimCentring on nursing homes, we analysed the implementation process of a tablet‐ and videoconferencing‐based telemedicine application from the perspectives of management, nursing staff and physicians.DesignWe used a qualitative design based on interviews to explore diverse perspectives on the implementation of telemedicine.MethodsWe conducted fourteen face‐to‐face or online interviews with a purposeful sample of five managers, six nurses and three general practitioners treating residents in Austrian nursing homes during the COVID‐19 pandemic. We condensed data using thematic analysis.ResultsNursing home management implemented telemedicine rapidly, using a top‐down approach met with ambivalence by staff. On the part of nurses, their professional understanding of person‐centred care was challenged. Telemedicine also impacted cooperation between nurses and physicians, influencing their respective understanding of their roles. Working experience with digital nursing documentation had a positive effect on users' acceptance of the telemedicine solution.

Updating the Standardized Terminology for Nurses' Daily Documentation.

In Finland, the nationally unified and standardized nursing documentation model comprises the nursing process model and the Finnish Care Classification (FinCC). The aim of the study was to assess how well the further developed FinCC complies with actual nursing practices and how pragmatic and understandable it is. An e-questionnaire based on the revised version of the FinCC was sent to healthcare organizations (n=34) and Universities of Applied Sciences (n=14). Data was gathered and organized in Excel. Narrative comments were read and analyzed. The mean of questions of 17 components of both the FICND and the FICNI was over four (scale 1-5). The biggest revision of the FinCC is that different scales and evidence-based research have been utilized in the development of the terminology. Based on the findings, revisions have been made, and the new version, FinCC 4.0, will be published at the end of 2019.

Ethical dilemmas in nursing documentation.

Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored. To explore ethical dilemmas in nurses' conversations about nursing documentation. The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman. This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent. Ethical dilemmas were strongly present in nurses' conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients' autonomy and not causing harm, which was visible in nurses' navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses' balancing between documenting deviations and proof of nursing practice. Ethical dilemmas in nursing documentation regarding respecting patients' autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records. Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.

774. Outbreak of Central-Line-Associated Bloodstream Infections (CLABSI) amid the COVID-19 Pandemic Associated with Changes in Central Line Dressing Care Accompanying Changes in Nursing Education, Nursing Documentation, and Dressing Supply Kits

BackgroundNational Healthcare Safety Network (NHSN) data have revealed an increase in CLABSI associated with the COVID-19 pandemic, but data on factors mediating the increase are limited. Our hospital had been free of CLABSI for 18 months, but we encountered an outbreak of 7 CLABSI over a 5-month period beginning in November 2020. This led to an investigation that revealed that some underlying issues were related to COVID-19.MethodsInfection prevention staff at Omaha’s Veterans Affairs Medical Center interviewed hospital staff and performed a retrospective chart review of patients with CLABSI (based on the NHSN definition) amid the COVID-19 pandemic.ResultsThe first case of CLABSI in the outbreak was detected in November 2020. Prior to that, there was no case of CLABSI since April 2019, as shown in the graph. Each case of CLABSI was associated with a different microorganism. Further investigation revealed deviations from our usual practices in central line dressing care. Our response to COVID-19 had included alterations in periodic competency training (including dressing care) for nursing staff as well as the rapid introduction of streamlined inpatient nursing documentation. Previously, dressing kits included chlorhexidine-impregnated dressings; in November, a kit without these dressings was introduced. A weekly audit of dressing care was begun in March 2021. No CLABSI was identified in April 2021.Types of Microorganisms identified Different types of microorganisms isolated during the CLABSI outbreak each month. The trend of CLABSI in VA Nebraska-Western Iowa Health Care SystemConclusionWe encountered a CLABSI outbreak associated with deviations from usual central line dressing care. Using the concept of the Swiss cheese model of error prevention, we recognized alterations in three barriers: competency training; thorough documentation; and complete supply kits. The first two of these factors were directly related to our COVID-19 response. Our findings illustrate the relevance of the Swiss cheese model for maintaining a safe healthcare environment.Disclosures Marvin J. Bittner, MD, Merck (Advisor or Review Panel member)Sanofi Pasteur (Speaker's Bureau)

147 ‘CHAMPIONING CONTINENCE’—ESTABLISHMENT OF A MULTIDISCIPLINARY CONTINENCE PROMOTION WORKING GROUP IN AN ACUTE TEACHING HOSPITAL

Abstract Background In line with the National Frailty Programme1, patients over the age of 75 admitted to hospital should have a comprehensive geriatric assessment including the assessment of current continence status and any history of incontinence. Up to 39% of adults are reported to develop new onset urinary incontinence during admission to hospital2,3, however studies show that is it a problem not always identified by staff members,4. In response to these observations within an acute teaching hospital, a continence working party was formed involving members of nursing, physiotherapy and occupational therapy colleagues to explore the current practice and culture relating to continence management. Methods The group established key objectives which were broken into four strands; 1. Audit of documentation of baseline continence on admission (therapy and nursing). 2. Obtaining access to additional types of continence wear. 3. Staff education. 4. Pre and post education survey. Results 1. Audit of documentation demonstrated poor standards of documentation of baseline continence. This led to an amendment to questioning prompts on therapy initial assessment forms and a plan to further evaluate the nursing documentation. 2. A wider array of continence wear has been made available on the wards providing greater options for patients. 3. Staff education session was compiled by a specialist physiotherapist and is widely available for staff to access on the hospitals online training portal. 4. Pre-education surveys have been completed with a view to re-administering following education roll-out. Conclusion The aim of this multidisciplinary working group is to equip staff with the correct resources, knowledge, and confidence to ensure best practice promotion of continence on the targeted wards. This project is the first strand of a wider culture changed that is needed around continence promotion for older adults in the acute setting.

FACTORS INFLUENCING DOCUMENTATION IN NURSING CARE BY NURSES AT THE TAMALE TEACHING HOSPITAL, GHANA

In Ghana, nursing documentation practice by nurses is sub-optimal. This analytical cross-sectional study assessed socio-demographic determinants of nursing documentation practice among 278 nurses at the Tamale Teaching Hospital (TTH). Data was gathered using a questionnaire and both descriptive and inferential analyses were done to determine factors influencing nursing documentation practice. A large majority of the respondents (84.6%) had adequate knowledge on nursing documentation. Most of them (84.2%) had positive attitudes towards it and a large majority of them (77.1%) asserted to practice it always but only 74.0% adequately practiced nursing documentation. Knowledge of nursing documentation was statistically associated with age (AOR 0.12, 95% C1: 0.029-1.507; p=0.004) and work experience (AOR 15.29, 95% C1: 3.083-75.872; p=0.001), males were significantly more likely to have positive attitudes towards it (AOR, 2.81 CI, 1.434-5.501, p=0.003) whilst respondents aged 21-30 years (AOR, 5.85 (2.64-12.97), p

Iron Infusion Reactions: Risk Factors and Real-World Experience

Introduction: Iron deficiency is the most frequent cause of anemia, which afflicts 32.9% of the global population and is a significant cause of morbidity worldwide. Oral iron is the first-line therapy for treating iron deficiency anemia; intravenous(IV) iron is used when oral iron is inappropriate, poorly tolerated or ineffective. The major adverse effect associated with IV iron is infusion-related reactions (IRR), ranging from mild reactions mediated by complement activation-related pseudo-allergy to anaphylaxis. In this study, we sought to determine rates and severity of iron IRR, identify patient characteristics associated with IRR and report strategies for subsequent iron repletion in patients who have IRR.Methods:We conducted a retrospective chart review of all patients older than 18 years who received IV iron from 1/1/2016 to 7/20/2021 in the outpatient Classical Hematology clinic at Yale New Haven Hospital. Demographics, risk factors, details of reactions and follow up were noted. The primary outcomes analyzed included rates and severity of IRR based on nursing and provider documentation and graded according to a previously-published IRR severity classification (Rampton D et al, Haematologica 2014;99:1671). Secondary outcomes included identification of patient characteristics associated with IRR utilizing Chi-square or Fisher's exact test for unadjusted analysis and logistic regression for multivariable analysis (IBM SPSS version 28).Results:A total of 330 patients, including 298 females, received IV iron. The common formulations used were ferumoxytol, iron sucrose and iron dextran with 199 (60.3%), 49(14.8%), and 36 (10.9%) patients, respectively, receiving each of these. Comorbid conditions were present in 317 (96.1%) patients, including 114 (34.5%) with cardiovascular disease (CVS) and 71 (21.5%) with asthma. Beta blocker or angiotensin-converting enzyme inhibitor (ACEI) use was noted in 90 (27.3%) patients. A history of allergies to medications was present in 167 (50.6%) patients while 139 (42.1%) had other non-drug allergies. The common indications for infusion were anemia due to heavy menstrual bleeding (27.6%), gastrointestinal bleeding (17.2%) and pregnancy (6.9%).Iron IRR was noted in 58 (17.6%) patients, of whom 36 (62.1%) had previously tolerated IV iron. Of the 58 patients with IRR, the median age was 40.32 ± 14.6 years; 30 (51.7%) had allergies to medications, 34 (58.6%) had non-drug allergies, and 13 (22.4%) each had a history of CVS or asthma. Beta blocker or ACEI use was found in 12 (20.7%) patients. The reaction manifestations included gastrointestinal in 16 (27.6%) patients, cardiovascular in 24 (41.4%), bronchopulmonary in 34(58.6%), mucocutaneous in 28(48.3%), neurological in 21(36.2%) and autonomic in 30 (51.7%). The severity of reaction was mild in 22 (37.9%) patients, moderate in 23 (39.7%), and severe in 11 (19%). After a reaction, 28 (48.3%) patients subsequently tolerated a different formulation of IV iron, while 14 (24.1%) patients tolerated the same formulation of IV iron at a slower rate with premedication; 5 (8.6%) patients had a subsequent reaction to a different IV iron formulation.Multivariable regression analysis was performed to examine associations of iron IRR with history of allergies to medications, non-drug allergies, asthma, CVS, use of beta blockers or ACEI and sex. In this analysis, a history of non-drug allergies was significantly and independently associated with greater odds of IRR (odds ratio (OR) 2.40, 95% confidence interval (CI): 1.32-4.37, p=0.004) while a history of CVS was associated with lower odds of IRR (OR 0.46, 95% CI: 0.22-0.988, p=0.047). None of the parameters were found to have an association with the severity of IRR.Conclusion:Iron IRR occurred in 17.6% of patients receiving IV iron, with severe reactions occurring in 3.3% of all patients; these rates are higher than those previously reported in literature. A history of non-drug allergies is independently associated with greater odds of IRR, and additional precautions may be indicated to prevent IRR in such patients. An association of CVS with lower odds of reaction may reflect anti-inflammatory effects of widespread aspirin use in these patients. The majority of patients with iron IRR can subsequently tolerate the same or a different formulation of IV iron with slower rates of infusion and premedication. [Display omitted] DisclosuresNeparidze: Janssen: Research Funding; GlaxoSmithKline: Research Funding; Eidos Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals

IntroductionElectronic nursing documentation is an essential aspect of inpatient care and multidisciplinary communication. Analysing data in electronic medical record (eMR) systems can assist in understanding clinical workflows, improving care quality, and promoting efficiency in the healthcare system. This study aims to assess timeliness of completion of an electronic nursing admission assessment form and identify patient and facility factors associated with form completion in three metropolitan hospitals. Materials and MethodsRecords of 37,512 adult inpatient admissions (November 2018-November 2019) were extracted from the hospitals’ eMR system. A dichotomous variable descriptive of completion of the nursing assessment form (Yes/No) was created. Timeliness of form completion was calculated as the interval between date and time of admission and form completion. Univariate and multivariate multilevel logistic regression were used to identify factors associated with form completion. ResultsAn admission assessment form was completed for 78.4% (n = 29,421) of inpatient admissions. Of those, 78% (n = 22,953) were completed within the first 24 h of admission, 13.3% (n = 3,910) between 24 and 72 h from admission, and 8.7% (n = 2,558) beyond 72 h from admission. Patient length of hospital stay, admission time, and admitting unit’s nursing hours per patient day were associated with form completion. Patient gender, age, and admitting unit type were not associated with form completion. DiscussionForm completion rate was high, though more emphasis needs to be placed on the importance of timely completion to allow for adequate patient care planning. Staff education, qualitative understanding of delayed form completion, and streamlined guidelines on nursing admission and eMR use are recommended.

Orthopaedic nurses’ experiences with real-time documentation in a high-tech ward: A qualitative study

BackgroundReal-time documentation is a novel process that changes nursing workflow; however, nurses’ experiences of real-time documentation are unknown. AimThis study aimed to explore nurses’ experiences with real-time documentation in an orthopaedic ward. DesignThis qualitative study took a phenomenological-hermeneutic approach. MethodsData were generated from three semi-structured focus group interviews with 18 nurses from an orthopaedic ward. Data analysis was based on Ricoeur's theory of narrative and interpretation and included naïve reading, structural analysis and critical interpretation, and discussion. ResultsFive themes emerged from the structural analysis: 1) nurses were initially sceptical and outside of their comfort zone; 2) implementation required support from the head nurse and other colleagues; 3) increased time with patients led to better relationships, but nurses lacked time for reflection; 4) increased patient involvement could also present challenges; and 5) documentation became more integrated into orthopaedic nursing. ConclusionReal-time documentation improved orthopaedic nursing documentation and increased patient involvement. Nurses spent more time with patients, leading to better relationships, but they had decreased time with their colleagues and the opportunity to reflect. Real-time documentation leads to changes in workflow, so, nurses should be provided with training and the opportunity to reflect.

A Comparison of Voice Recognition Program and Traditional Keyboard Charting for Nurse Documentation.

The purposes of this study are threefold: (1) compare the document times between a voice recognition system and keyboard charting, (2) compare the number of errors between the two methods, and (3) identify factors influencing documentation time. Voice recognition systems are considered a potential solution to decrease documentation time. However, little is known to what extent voice recognition systems can save nurses' documentation time. A pilot, simulation study was conducted using a voice recognition system and keyboard charting with 15 acute care nurses. A crossover method with repeated measures was utilized. Each nurse was given two simple and two complex assessment scenarios, assigned in random order, to document using both methods. Paired t-tests and multivariate linear regression models were used for data analysis. The voice recognition method saved the nurses 2.3 minutes (simple scenario) and 6.1 minutes (complex scenario) on average and was statistically significant (P < .001). There were no significant differences in errors or factors identified influencing documentation times. Eighty percent reported a preference of using voice recognition systems, and 87% agreed this method helped speed up charting. This study can show how a voice recognition system can improve documentation times compared with keyboard charting while still having thorough documentation.

Translation and cross-cultural adaptation of the Clinical Care Classification system

IntroductionThe Clinical Care Classification (CCC) system is one of the standard nursing terminologies recognized by the American Nurses Association, developed to describe nursing care through electronic documentation in different healthcare settings. The translation of the CCC system into languages other than English is useful to promote its widespread use in different countries and to provide the standard nursing data necessary for interoperable health information exchange. The aim of this study was to translate the CCC system from English to Italian and to test its clinical validity. MethodsA translation with cross-cultural adaptation was performed in four phases: forward-translation, back-translation, review, and dissemination. Subsequently a pilot cross-mapping study between nursing activities in free-text nursing documentation and the CCC interventions was conducted. ResultsAll elements of the CCC system were translated into Italian. Semantic and conceptual equivalences were achieved. Altogether 77.8% of the nursing activities were mapped into CCC interventions. ConclusionsThe CCC system, and its integration into electronic health records, has the potential to support Italian nurses in describing and providing outcomes and costs of their care in different healthcare settings. Future studies are needed to strengthen the impact of the CCC system on clinical practice.

Assess the knowledge and attitude practices regarding nursing care documentation among staff nurses in SMCH

Assess the knowledge and attitude practices regarding nursing care documentation among staff nurses in SMCH

An evaluation of a unified practice assessment document for student nurses: Students’, mentors’ and academics’ views and experiences

Assessment of students’ performance in practice is an essential part of a health and social care education programme. In the United Kingdom, most nursing practice assessment documentation is specific to each university, leading to concerns about consistency. This paper’s aim is to present the development and evaluation of a unified practice assessment document. Nine London universities worked collaboratively with stakeholders to develop a pan-London practice assessment document, which aimed to increase consistency and quality of practice assessment. The evaluation aimed to investigate the views of nursing students, mentors and academics regarding implementation and use of the document in practice. Focus groups were conducted with students (n=46 in 6 groups), mentors (n=46 in 7 groups) and academic staff (n=42 in 6 groups) and the data were analysed using the framework approach. Four themes are presented: a robust and consistent approach; assessing professional values; essential skills acquisition; service user involvement. The new document was considered to foster consistency, reduce confusion and workload for mentors, and promote standardisation for practice assessment of student nurses across London.

Improving the quality of nursing documentation at a residential care home: a clinical audit

BackgroundQuality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice.MethodsA criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0–3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019.ResultsNone of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95 % confidence interval 0.3–0.6) for “aims for nursing care” to 1.1 (0.9–1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8–1.1) for “evaluation/progress reports” to 1.9 (1.5–2.2) for “nursing assessment on admission”.ConclusionsA criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

Nursing Praxis for Reducing Documentation Burden Within Nursing Admission Assessments.

The purpose of this quality improvement project was to conduct a scholarly assessment of the information collected within the nursing admission encounter and implement content revisions across three pilot medical surgical units. The guiding principles were to preserve regulatory information, identify nurse-sensitive data, and eliminate nonessential information. The goal was to decrease the number of clicks and time expended to document electronically an acute admission encounter by 20% and to project the number of hours returned to patient care as a result of decreasing computer clicks. A second goal was to quantify the projected costs of completing a nursing admission encounter. This quality improvement project leveraged nurse executive competencies to intersect the nursing process to develop a nursing documentation praxis. This author's praxis reduced nursing documentation burden in clicks by 29% and reduced time to document on an admission encounter by 34%. This restored the focus on nurse-patient interactions by returning 1016 hours per year to patient care activities, across three pilot units, as well as quantified the costs of completing a nursing admission assessment to utilize in future cost analysis of nursing tasks.

Identifying nursing documentation patterns associated with patient deterioration and recovery from deterioration in critical and acute care settings

ObjectivesNursing documentation behavior within electronic health records may reflect a nurse’s concern about a patient and can be used to predict patient deterioration. Our study objectives were to quantify variations in nursing documentation patterns, confirm those patterns and variations with clinicians, and identify which patterns indicate patient deterioration and recovery from clinical deterioration events in the critical and acute care settings. MethodsWe collected patient data from electronic health records and conducted a regression analysis to identify different nursing documentation patterns associated with patient outcomes resulting from clinical deterioration events in the intensive care unit (ICU) and acute care unit (ACU). The primary outcome measures were whether patients were discharged alive from the hospital or expired during their hospital encounter. Secondary outcome measures were clinical deterioration events. ResultsIn the ICU, the increased documentation of heart rate, body temperature, and withheld medication administrations were significantly associated with inpatient mortality. In the ACU, the documentation of blood pressure, respiratory rate with comments, singular vital signs, and withheld medications were significantly related to inpatient mortality. In contrast, the documentation of heart rate and “as needed” medication administrations were significantly associated with patient survival to discharge in the ACU. ConclusionWe successfully identified and confirmed the clinical relevancy of the nursing documentation patterns indicative of patient deterioration and recovery from clinical deterioration events in both the ICU and ACU.

Nursing interruptions in emergency room in China: An observational study

To analyse the frequency and core elements of nursing work interruptions in Chinese emergency nursing settings. Little is known about nursing interruptions, which affect the quality of services in Chinese emergency nursing setting. A cross-sectional observational study was conducted in three units of an emergency department in a Chinese tertiary hospital. Participants comprised 60 nurses. Data were collected using a questionnaire developed by the researchers specifically for this study. In total, 25,965min of work was observed and 2333 interruptions were identified. Most interruptions were from patients, their families and nurses. Therapeutic nursing and patient observation and documentation were the most frequently interrupted procedures. Most interruptions were negative, and a majority of the nurses immediately responded to interruptions. Significant differences existed in the overall distribution of the core elements among the three nursing units. The frequency of emergency nursing interruptions was moderate. Most interruptions tend to lead to negative treatment outcomes for patients. Emergency nursing managers should recognize the importance of interruptions, understand work situations better and develop ways to reduce the incidence of interruptions. Thus, nursing risks can be avoided by reducing the adverse outcomes caused by work interruptions.

Pengembangan Format Dokumentasi Asuhan Keperawatan Gawat Darurat Berbasis SDKI, SLKI, dan SIKI

This study aims to determine the development of the emergency nursing care documentation format based on the IDHS, SLKI, and SIKI, the quality of the format development, and the quality of the documentation for the development of the design in the Emergency Room of Dradjat Prawiranegara Hospital Serang Banten. The research method is Research and Development. The result of this research is that the nursing diagnosis is determined according to the primary assessment. The quality of developing the emergency nursing care documentation format is functional, efficient, and usable. And the quality of emergency nursing care documentation includes completeness, accuracy, relevance, and good novelty. In conclusion, the format of nursing care documentation based on IDHS, SLKI, SIKI can be used in the emergency room to improve the quality of nursing care.&#x0D; &#x0D; Keywords: Documentation of Emergency Nursing Care, IDHS, SLKI, SIKI