Documentation Of Nursing Assessment Research Articles

Abstract TP43: Optimizing System-Wide Nursing Assessment Documentation in the Stroke Population

Background: Stroke centers following AHA guidelines for the treatment of acute ischemic stroke, are challenged by compliance with documentation of vital sign, neuro and neurovascular assessments post thrombolysis interventions. Standardizing documentation in the electronic health record (EHR) increases compliance and reduces patient harm. In a large healthcare system, multiple sites received corrective action findings from regulatory agencies for missed nursing assessments. The centers did not have a documentation workflow aligned with the EHR to capture assessments in the stroke population. Purpose: To create a system-wide documentation workflow that captures nursing assessments in the EHR. Methods: In 2019 a task force of stroke coordinators and clinical informaticists convened to define evidence-based nursing assessments in stroke patients post intervention, define within normal limits for each component, and identify barriers to documentation in the EHR. The EHR was evaluated for component location and other areas in need of optimization. Components were scattered across different EHR locations, leading to missing documentation and assessments were difficult to trend. The task force led the development and implementation of a single EHR location to document nursing assessments. The EHR revisions were implemented in July 2022 after being vetted by system EHR governance, nurse practice council, and stroke coordinator collaborative. Results: A single grouping was developed in the EHR including vitals, focused neurological and neurovascular assessments. This grouping was strategically placed within nursing’s existing workflow. Reference text addressing each element of the grouping and its “within defined limits’ definition were added to align with the organization's documentation standards. To increase visibility of documentation, trending, and the auditing process, a single results view was developed which included all documented assessment components. Conclusion: A system-wide documentation workflow aligned with the EHR optimized documentation workflow, improved visibility of assessments, reduced audit time and regulatory findings. Stroke centers should carefully consider the layout of nursing documentation in the EHR.

Implementing a Care Plan System in a Community Hospital Electronic Health Record.

Nursing care plans, the result of the nursing process, are important because they guide quality patient care, define the nurse's role in patient treatment, and support patient specific nursing interventions. Nurse leaders at a community hospital identified that 70% of hospitalized patients shared the same three nursing problems and three-day resolution target dates. This quality improvement project involved the implementation of a nursing care plan system within the organization's existing electronic health record platform that supported the development of individualized plans. The implementation included a) integration of care plan activities into the nursing workflow, b) adoption of a standardized nursing language to provide structure nursing care plan data capture and reporting, c) configuration of the electronic health record to recommend patient data-driven care plan problems based on nursing assessment documentation; and d) trended care plan data to identify problem patterns within the patient population. A postimplementation audit indicated a 130% improvement in achieving individualized care plans within 24 hours of admission.

INCREASE THE COMPLETENESS OF THE NURSING DOCUMENTATION THROUGH THE IMPLEMENTATION OF THE NURSING INITIAL ASSESSMENT FORMS

Nu rse had limited time t o perform nursing documentation due to dense work load and limited number of nurse as well as the narrative format of documentation. Therefore, nursing assessment documentation was frequently incomplete. The study aim was to determine the effect of initial nursing assessment form aton the completeness of nursing assessment documentation in the internal ward of Padang Panjang District Hospital in year 2016. The study design was action research. Bivariate analysis was done by W ilcoxon ’s test and multivariate analysis was done by F riedman ’s test. R esult showed that the implementation of nursing initial assessment checklist form at increase the completeness of the nursing initial assessment documentation (p = <0.05). N ursing initial assessment checklist form at could be applied to improve the completeness of nursing assessment documentation. It is r ecomme nded to hospital management to set the nursing initial assessment checklist form at as the standard form at usedand provide supervision and evaluation of this program . Key w ords : checklist, in nitial a ssessment, d ocumentation

Model documentation of assessment and nursing diagnosis in the practice of nursing care management for nursing students

&lt;p&gt;Model documentation of assessment and nursing diagnosis in the practice of nursing care management is an integration model in nursing care records, especially records nursing assessment and diagnosis in one format. This model can reduce the duration of the recording in nursing care, and make it easier for students to understand the nursing diagnosis, so that nursing interventions more effective. The purpose of this paper was to describes the form integration documentation of nursing assessment and diagnosis of nursing in nursing care management for nursing students. This literature review was done by searching the following search engine: Pubmed, Midline, EBSCO, and Google Scholar. Data in the synthesis from nursing diagnoses of NANDA-I were incorporated into the of nursing assessment form using Gordon’s functional health pattern. Types of articles included: original research, and literature review. This review of article includes 1) introduction 2) form of nursing assessment documentation 3) implementation of nursing diagnosis documentation 4) the implementation strategy documentation of assessment and nursing diagnosis 5) recommendation for nursing education 6) conclusion.&lt;/p&gt;

Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes

PurposeTo describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment. MethodsThis was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated. ResultsVarying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms). ConclusionsElectronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

The Adequacy of ICNP Version 1.0 as a Representational Model for Electronic Nursing Assessment Documentation

The purpose of this study was to evaluate the adequacy of the International Classification of Nursing Practice (1) (ICPN) Version 1.0 as a representational model for nursing assessment documentation. To identify representational requirements of nursing assessments, the authors mapped key concepts and semantic relations extracted from standardized and local nursing admission assessment documentation forms/templates and inpatient admission assessment records to the ICNP. Next, they expanded the list of ICNP semantic relations with those obtained from the admission assessment forms/templates. The expanded ICNP semantic relations were then validated against the semantic relations identified from an additional set of admission assessment records and a set of 300 randomly selected North American Nursing Diagnosis Association defining characteristic phrases. The concept coverage of the ICNP was evaluated by mapping the concepts extracted from these sources to the ICNP concepts. The UMLS Methathesaurus was then used to map concepts without exact matches to other American Nursing Association (ANA) recognized terminologies. The authors found that along with the 30 existing ICNP semantic relations, an additional 17 are required for the ICNP to function as a representational model for nursing assessment documentation. Eight hundred and five unique assessment concepts were extracted from all sources. Forty-three percent of these unique assessment concepts had exact matches in the ICNP. An additional 20% had matches in the ICNP classified as narrower, broader, or "other." Of the concepts without exact matches in the ICNP, 81% had exact matches found in other ANA recognized terminologies. The broad concept coverage and the logic-based structure of the ICNP make it a flexible and robust standard. The ICNP provides a framework from which to capture and reuse atomic level data to facilitate evidence-based practice.

Nursing assessment documentation and care of hip fracture patients’ skin

Summary The aims of the present study were to describe and compare documented nursing assessment and care of skin in hip fracture patients in two settings. A retrospective review was made of 170 inpatient records from one county hospital (hospital A) and two local hospitals (hospital B), all in one county council in Sweden. In more than half (60%) of the records at arrival and in 78% on discharge a skin assessment was evident. Notes about pressure ulcers were included in 15% of all patient records at arrival and 20% on discharge. The registered nurses in hospital B risk assessed significantly more patients with the Modified Norton Scale compared with hospital A. Patients who were assessed with the Modified Norton Scale received more interventions than patients not assessed. Further, patients with a low Modified Norton Scale score, received interventions to a higher extent and patients with high Modified Norton Scale score received interventions to a minor extent. The most frequent measured interventions were turning schedule, fluid and food intake. The comprehensiveness in the nursing notes was acceptable in only 9% of the patient records. This study highlights the need for continuous audit of patient records with feedback to registered nurses (RNs) in order to follow the quality indicators and national principle for pressure ulcer prevention.