Nursing Documentation Research Articles

Improving pediatric experience of pain during vaccinations: a quality improvement project.

The purpose of this paper is to share lessons learned from a quality improvement (QI) project that studied pediatric pain assessment scores after implementing additional evidence-based pain mitigation strategies into practice. Most nurses will acknowledge they implement some practices to mitigate pain during injections. Addressing pain during vaccination is important to prevent needle fear, vaccine hesitancy and health care avoidance. The aim of this project was to reduce pain as evidenced by pain scores at the time of vaccination at the North Bay Nurse Practitioner-Led Clinic (NBNPLC). The design for this study was quasi-experimental utilizing descriptive statistics and QI tools. The NBNPLC utilized the model for improvement to test change ideas. A validated observation tool to assess pain during vaccination with the pediatric population (revised Face Legs Activity Cry and Consolability) was used to test changes. The team deliberately planned improvements according to best practice guidelines to optimize use of strategies to mitigate pain during injections. QI tools and leadership skills were utilized to improve the pediatric experience of pain during vaccinations. Parents and clinicians provided qualitative and quantitative feedback to the project. Nurses tested pain assessment tools and agreed to use a validated tool to assess pain during vaccinations. Parents agreed to use of topical anesthetic during vaccinations. Improved pain scores during vaccinations were demonstrated with the use of topical anesthetic. Parents agreed to use of standardized sucrose solution during vaccination. Reduced pain scores were observed with the use of standardized sucrose water. To sustain implementation of the guideline, a nursing documentation form was devised with nurses agreeing to ongoing use of the form. This is a QI project that examined the intricacies of moving clinical practice guidelines into clinical practice. The project validates guidelines for pain management during vaccinations. Leaders within clinics who want to improve pediatric pain during vaccinations will find this paper helpful as a guide. Pain management in the pediatric population will be touched on in the context of parental expectations of pain. QI tools, lessons learned and suggestions for nurses will be outlined. Leadership plays an influential role in translating practice guidelines into practice. This paper outlines how organizational supports were instrumental to give clinicians time to deliberately challenge practice to improve quality of care of children during vaccinations.

Pengembangan Dokumentasi Keperawatan Berbasis Elektronik Di RS X Kota Depok Dengan Menggunakan Teori Perubahan Lewins

Background: Nursing documentation in Indonesia is still much in the form of paper based documentation. Many weaknesses in this documentation model, so it needs to be innovated by using electronic-based nursing documentation. Problems that occur in RS X in the development of electronic-based nursing documentation are the factors of leadership, factors of means and factors of follow-up development of electronic nursing documentation. Method: In solving this problem, it is recommended to use Lewin's theory of change which consists of three phases: unfreezing, moving, and refreezing. Result: Stages of unfreezing: conducting evidence-based and literature review studies on the importance of electronic documentation, and brainstorming with the nurse actors change Phase Moving implementing the stages of implementation of electronic documentation development using the principles of 5 management functions namely planning, organizing, staffing, leading and controlling. Refreezing stages: provide supervisors, make Decree of Director and Standard of Operational Procedure about implementation of electronic-based nursing documentationin X Hospital Depok. Conclusion: In solving this problem, Lewin's theory of change consists of three pairs, namely unfreezing, moving, and refreezing.

Nurses’ Experiences and Perceptions of Hourly Rounding: A Private Australian Catholic Hospital Single Case Study

Aim: This research paper reports on nurses’ experiences and perceptions of hourly rounding undertaken at private Catholic acute care regional hospital in Australia. Background: Evidence suggests that structured nursing rounds are associated with positive outcomes. However, a number of barriers to effective hourly rounding have been reported. Rounding practices were implemented in a medical/ surgical ward at a regional hospital in Australia, in 2014, aiming to reduce the risk of patient falls and enhance the patient experience. Methods: A qualitative, exploratory descriptive single case study design was utilised. Fifteen (15) nurses participated in the study and data were generated using Hermeneutic phenomenological interview technique. Transcriptions of each interview were analysed using both content and thematic analysis approaches. Results: The experiences and perceptions of the nurse participants involved in the study were found to centre on the following themes and subthemes: 1. Support for rounding practice 2. Barriers to rounding practice a) High workload and time-pressure b) Documentation Conclusion: The implementation of rounding was perceived to be useful and overall supported by the participants. Relocating nursing documentation and reviewing the model of care were highlighted as recommendations to improve compliance and support ongoing sustainability of rounding.

Implementing mandatory early warning scoring impacts nurses' practice of documenting free text notes.

To evaluate whether implementing the Modified Early Warning Scoring system impacts nurses' free text notes related to Airway, Breathing, Circulation and Pain in general ward medical and surgical patients. The quality of nursing documentation in patient health records is important to secure patient safety, but faces multiple challenges whether being paper-based or electronic. Nurses' ability to draw a complete picture of the patient situation is thereby compromised. Structured use of the Modified Early Warning Score, found to reduce unexpected death, might affect nurses' free text documentation of clinical observations. A prospective, pre- and postinterventional, nonrandomised study adhering to the EQUATOR guideline TREND. Data on nurses' free text notes were obtained in 1,497 patient records during one preinterventional (March-June 2009) and two postinterventional study periods (September-December 2010 and March-June 2011) in a Danish university hospital. Data were organised by the Airway, Breathing and Circulation principles and by nurses' working shifts in the 56hr surrounding the first recording of deviating vital parameters or a Modified Early Warning Score≥2. Preinterventional free text notes were compared with notes from the two postinterventional periods, respectively. In the 8-hr working shift where deviations in vital parameters were recorded for the first time, nurses' free text notes related to patients' breathing (B) increased significantly, comparing 2009 with 2010 and 2011, respectively. In the 24hr following initial deviations in vital parameters, a significant increase in free text notes was identified concerning Airway, Breathing and Circulation-related symptoms or problems. Mandatory use of the Modified Early Warning Score and related implementation activities significantly impacts nursing documentation of free text notes. Nurses' practice of communicating observed clinical symptoms by documenting free text notes should be supported through measures to enhance situation awareness.

A CONTINUITY ANALYSIS OF INDEPENDENT NURSING CARE DOCUMENTATION USING THE FISHBONE DIAGRAM IN THE TERATAI ROOM NORTH 2ND FLOOR X HOSPITAL, JAKARTA


 Quality nursing care documentation based on facts, accurate, complete, concise, organized, timely, easy to read, and continuity. Continuity of nursing care is fulfilled if the range of health services is appropriate, the availability of quality caregivers professionals and information related to patient care are delivered on an ongoing basis. The method used is a case study with observation, interviews, secondary data and document review. This study that is an innovation project, uses a fish bone diagram approach to identify the causes of the discontinuity independent nursing care documentation. Documentation of evaluation of independent nursing care for the development of patients in the midwifery and ginecology room in X Hospital in Jakarta has not reflected the continuity of nursing care. The causes include the lack of optimal competence in providing independent nursing care, not optimal nursing manager functions. The continuity is overcome by optimizing the nursing manager's function by making SOP note integrated patient development, revision of midwife's job description, revision of guide to nursing practice, electronic-based documentation system, placing midwives in accordance with the service area the authority and standard of the profession, the structured supervision schedule, and make sure the midwife's job description is in accordance with the policy.
 
 
 

Nurse Documentation of Sexual Orientation and Gender Identity in Home Healthcare: A Text Mining Study.

Health disparities have been documented in the lesbian, gay, bisexual, and transgender population, but more research is needed to better understand how to address them. To that end, this observational study examined what is documented about sexual orientation and gender identity in narrative home care nurses' notes in an electronic health record. Lexical text mining approaches were used to examine a total of 862 715 clinical notes from 20 447 unique patients who received services from a large home care agency in Manhattan, New York, and extracted notes were qualitatively reviewed to build a lexicon of terms for use in future research. Forty-two notes, representing 35 unique patients, were identified as containing documentation of the patient's sexual orientation or gender identity. Documentation of sexual orientation or gender identity was relatively infrequent, compared to the estimated frequency of lesbian, gay, bisexual, and transgender people in the US population. Issues related to fragmentary language emerged, and variety in phrasing and word frequency was identified between different types of notes and between providers. This study provides insight into what nurses in home healthcare document about sexual orientation and gender identity and their clinical priorities related to such documentation, and provides a lexicon for use in further research in the home care setting.

HUBUNGAN MOTIVASI KERJA PERAWAT DENGAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN RAWAT INAP DI RUMAH SAKIT SENTRA MEDIKA CISALAK

Introduction nurses must have motivation in work, especially in documentation. Documentation of the nursing process includes assessment, problem identification, planning, nurse actions, then observing and evaluating the client's response to the action given and informing the information to other health workers. The results of data obtained in documenting inpatient nursing care there are completeness targets that have not been achieved. The purpose of the study was to determine the relationship between nurses' work motivation and documenting inpatient nursing care at the sentra medika cisalak hospital. Research method is descriptive correlative with cross-sectional approach. The total population is 50 respondents in the adult inpatient room. Results based on the results of the study there were 52.0% of respondents had high work motivation and 62.0% of nursing care documentation that had been done. With the value of Chi Square = 0.002 <0.05, the HA hypothesis is accepted. The conclusion is that there is a relationship between nurses' inpatient work motivation in the hospital center medica cisalak (0.6138) which means “strong”. Suggestions for nurse who have implemented nursing care documentation provided rewards / awards from superiors and audits are carried out continuously.

Nurses' Perceptions of a Care Plan Information Technology Solution With Hundreds of Clinical Practice Guidelines in Adult Intensive Care Units: Survey Study.

BackgroundThe integration of clinical practice guidelines (CPGs) into the nursing care plan and documentation systems aims to translate evidence into practice, improve safety and quality of care, and standardize care processes.ObjectiveThis study aimed to evaluate nurses’ perceptions of the usability of a nursing care plan solution that includes 234 CPGs.MethodsA total of 100 nurses from 4 adult intensive care units (ICUs) responded to a survey measuring nurses’ perceptions of system usability. The survey included 37 rated items and 3 open-ended questions.ResultsNurses’ perceptions were favorable with more than 60.0% (60/100) in agreement on 12 features of the system and negative to moderate with 20.0% (20/100), to 59.0% (59/100) in agreement on 19 features. The majority of the nurses (80/100, 80.0% to 90/100, 90.0%) agreed on 4 missing safety features within the system. More than half of the nurses believed they would benefit from refresher classes on system use. Overall satisfaction with the system was just above average (54/100, 54.0%). Common positive themes from the narrative data were related to the system serving as a reminder for complete documentation and individualizing patient care. Common negative aspects were related to duplicate charting, difficulty locating CPGs, missing unit-specific CPGs, irrelevancy of information, and lack of perceived system value on patient outcomes. No relationship was found between years of system use or ICU experience and satisfaction with the system (P=.10 to P=.25).ConclusionsCare plan systems in ICUs should be easy to navigate; support efficient documentation; present relevant, unit-specific, and easy-to-find information; endorse interdisciplinary communication; and improve safety and quality of care.

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews.

To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. Systematic review of systematic reviews. We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches. Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis. Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation. There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.

The role of psychological distress in the relationship between the severity of pressure injury and pain intensity in hospitalized adults.

To examine the effect of psychological distress in mediating the relationship between the severity of pressure injury and pain intensity in hospitalized adults. Despite the prevalence of pressure injury (previously known as pressure ulcers) in hospitalized adults, the current knowledge of pain associated with pressure injury is limited and findings are inconsistent. There is also a lack of understanding of the relationship between psychological distress and pain from pressure injury. Retrospective cross-sectional secondary analysis of data from electronic health records. The data were retrieved from the third day of admission in the period between 2013 - 2016 through the Integrated Data Repository (IDR). Electronic health records were reviewed to collect data as needed. The mediation effect was tested by using path analysis implemented through Mplus. Path analysis revealed that the severity of pressure injuries and psychological distress have significant direct effects on pain intensity in hospitalized adults. However, the relationship between the severity of pressure injury and pain intensity was not significantly mediated by psychological distress. Hospitalized adults who have more severe pressure injury and more treatments for psychological distress experienced greater pain intensity. Healthcare providers must pay attention to treating psychological distress among hospitalized adults to manage pain. Further study is needed to validate these findings and it should incorporate more appropriate measures of psychological distress. The lack of standardized nursing documentation in electronic health records severely limits the usefulness of data from electronic health records for nursing research.

The Implementation of Electronic based Nursing Care Documentation to EFETEC; A Literature Review

ABSTRACT
 In last two decades most of the tasks performed by nurses have not been directly related to patient care. Nurses spend more time on writing documentation or medical records of patients. Implementation of electronic medical record can reduce the time used for documentation or in other hand will increase the time for nurses to interact with patients then eventually can improve the quality of nursing care. Purpose of this literature review is to find out the implementation of electronic-based nursing care documentation (EHR) in improving the quality of nursing care in terms of EFETEC aspects. Method used by author is a literature review. Database used is Science Direct, PROQUEST, Scopus, Ebscho and Scholar Article with the keywords; electronic health record, EHR, Documentation in nursing, Quality of nursing care. Implementation of electronic nursing care documentation can improve the service quality. Improvement of the quality of service is reviewed with EFETEC which consists of efficient, focus for patient, effective, time discipline, equality, confidentiality. In the era of health workers 4.0 the utilization of electronic nursing care documentation requires continuous development in order to improve the quality of service for patients.
 KEYWORDS: electronic health record, nursing care documentation, quality of nursing care

Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

Background: Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity.Objective: The Purpose of research to identify the legal aspect and completeness of nursing documentation after applying electronic nursing documentation.
 Methods: Report study approach and using pre and post-test with the control group. Thirty Four documentation collected using consecutive sampling on one-week observation before and after using electronic nursing information. The research compared the legal aspect and completeness of data conducted before and after the implementation of the new system.Results: The study showed improvement of the legal aspects increased by 50% (4,40 to 8,00) and completeness documentation by 10.39% (43,00 to 49,00) after used of a system. 
 Conclusion: Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care.
 Recommendation: Electronic nursing documentation can be done to support and increase the quality of nursing.

Assessment of documentation on current medical records of patients in Accident and Emergency Hospital of Sulaimani-Iraq

The patient record is an essential patient data were the nursing documentation part is fundamental. .Competent nursing care is based on correct and complete records, and keeping record is an essential skill that needs to be developed by each and every health staff. The present study was conducted in order to assess the documentation on current medical patient’s records in the Accident and Emergency Hospital/Sulaimani city. A quantitative descriptive design. Research was accomplished, based on retrospective data made available by the Accident and Emergency Hospital. Non-probability (purposive sample) of 201 patient files were selected from 1,194 patient files during 6 months between Jun to December 2016.The present study showed that the face sheet was completely recorded about %95 which means satisfactory, other items which were recorded by physician such as chief complaint and history of present illness, radiology, laboratory, medication intervention report, consent forms, physical examination, and consultant report were unsatisfactorily recorded. Last items which were recorded by the nurse who working in Accident and Emergency Hospital medication and administration record and a graphic sheet of vital signs were unsatisfactorily recorded. Deficiency in documentation system and most of the provided medical and nursing care remains undocumented given numerous deficiencies in the documentation system. It is recommended the components of the nursing record tool can be utilized once a paperless system is implemented as planned in the hospital.

Metode Pendokumentasian Elektronik dalam Meningkatkan Kualitas Pelayanan Keperawatan

Nursing documentation is one of the most important functions for nurses in providing nursing care. The nursing process in the modern era is now a demand from various aspects for nurses. The current development is that nurses must carry out nursing processes based on nursing care standards. The use of electronic nursing documentation can always evolve in line with technological developments, this can increase client life expectancy and reduce errors in intervening with clients. This IT-based documentation system will help in meeting documentation standards, can improve the quality of documentation, facilitate decision making and provide information that is easy to access, can minimize the potential for loss or damage to development records, improve information exchange and coordination between nurses or other health teams, documentation can be easily audited, help improve the accuracy of client data, can access the progress of client health development and reduce maintenance costs so that it can improve the quality of care services.

Data collected by the electronic health record is insufficient for estimating nursing costs: An observational study on acute care inpatient nursing units

Introduction As the electronic health record becomes more sophisticated, commensurate advances in cost accounting have risen as a top priority for hospital leaders. This study explored: 1) the average time to complete common nursing tasks documented in the electronic health record, 2) nursing-related tasks that remain undocumented, 3) the association between observation data and actual nursing documentation, and 4) considerations for model development and report design to be used for activity based cost accounting in nursing.Methods This was an observational study completed on acute care inpatient nursing units at a large academic medical center. During a five-week period, 63 nurses from 25 units were observed for over 250 h.Results Nearly 60% of the observed nursing activities did not fit into categories readily available in, and easily abstracted from, the electronic health record. The undocumented activities accounted for over half of the observation tasks and equated to nearly 130 h, in which over 40 h were spent on the activity of documentation/charting itself. Furthermore, nearly 36 h were spent on communication, followed by 13.5 h on monitoring/surveillance, two critical tasks in nursing which cannot be overlooked.Conclusions Using the electronic health record for cost accounting in nursing is a novel approach. In addition to the electronic health record, supplementary sources of data must be included to accurately capture nursing work and associated costs. Findings and lessons learned from this study will be used to guide future work and develop a model that determines the cost of nursing care and improved value in hospitalized patients.

Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review.

To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings. Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper-based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety. We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings. Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content. Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections. A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.

PENGETAHUAN MAHASISWA DIII KEBIDANAN STIKES SANTA ELISABETH MEDAN TENTANG KELENGKAPAN PENCATATAN REKAM MEDIS

Hospitals as one of the health care facilities are required to make medical records. Medical records are written evidence of services provided by doctors that contain patient identity, examination, treatment, other actions and services that have been given to patients. Midwives as medical personnel who also provide health services have an obligation to make documentation of their midwifery care actions. Aim: This study aimed to analyze the relationship of midwifery DIII student knowledge about medical records with the completeness of filling in midwifery care documentation. Methode: This research was an analytic observational study with cross sectional design. The study population was all third level midwifery DIII students who served at Santa Elisabeth Hospital in Medan and were directly involved in filling in medical records. Data was obtained by observed the completeness of filling nursing care documentation in the medical record for the period August 1st-31st, 2018 and used a questionnaire to assess the level of knowledge of midwifery students about medical records (procedures for filling and legal aspects). Statistical test using Chi Square test. Result: In this study found significant results between variables of knowledge about the legal aspects of medical records (p = 0.011), procedures for filling nursing care documentation (p = 0.001). Variables of knowledge about medical records get significant results, namely (p = 0.004). Conclusion: There were a meaningful relationship between the knowledge of Midwifery DIII students about medical records with the completeness of filling in midwifery care documentation. Keywords: Students of DIII Midwifery, Knowledge, Medical Records, Midwifery Care Documentation.

Emergency Airway Response Team (EART) Documentation

Patients in an acute care hospital who experience a difficult airway event outside the operating room need a specialized emergency airway response team (EART) immediately. This designated team manages catastrophic airway events using advanced airway techniques as well as surgical intervention. Nurses respond as part of this team. There are no identified difficult airway team documentation instruments in the literature, and the lack of metrics limits the quality review of the team response. This study identified EART documentation criteria and incorporated them into a nursing documentation instrument to be completed by a nurse scribe during the event. The EART instrument was tested by nurses for usability, feasibility, and completeness. Twenty-one critical care nurses participated in this study. The results confirmed good usability, positive feasibility, and 79% documentation completeness using this tool. These criteria and this instrument can be important in documenting the EART and in evaluating the quality of the team performance.

Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran.

BACKGROUND:Standardization of documentation has enabled the use of medical records as a primary tool for evaluating health care functions and obtaining appropriate credit points for medical centres. However, previous studies have shown that the quality of medical records in emergency departments is unsatisfactory.AIM:The aim of this study was improving the nursing care documentation in an emergency department, in Iran.MATERIAL AND METHODS:This collaborative action research study was carried out in two phases to improve nursing care documentation in cooperation with individuals involved in the process, from February 2015 to December 2017 in an affiliated academic hospital in Iran. The first phase featured virtual training, an educational workshop, and improvements to the hospital information system. The second phase involved the recruitment of human resources, the implementation of continuous codified training, the establishment of an appropriate reward and penalty system, and the review of patient education forms.RESULTS:The interventions improved nursing documentation quality score of 73.20%, which was the highest accreditation ranking provided by Iran’s Ministry of Health and Medical Education in 2017. In other words, this study caused a 32% improvement in the quality of nursing care documentation in the hospital.CONCLUSION:The appropriate practices for improving nursing care documentation are employee participation, managerial accountability, nurses’ adherence to documentation standards, improved leadership style, and continuous monitoring and control.

Nursing Processes Related to Unexpected ICU Admissions

Nurses have the knowledge and skills to recognize and intervene when the condition of patients on medical or surgical units deteriorates. Despite this, deterioration is sometimes missed resulting in unexpected ICU admissions. This study explored the nursing process factors associated with unexpected ICU admissions. A chart audit was undertaken in a large urban hospital and data were collected measuring nursing assessment (vital signs), communication and documentation. Results showed that the most common reason for an unexpected ICU admission was respiratory distress. At the same time, respiratory rate was the least documented vital sign. Communication, documentation and recognition of patient deterioration play a key role in intervening and preventing unexpected ICU admissions. Attention to adequate staffing levels as well as implementation of clinical tools may assist nurses to more readily address patient deterioration and prevent unexpected ICU admissions.