Nursing Documentation Research Articles

Pain Reassessment & Documentation

The Joint Commission standards guides nursing documentation of pain reassessment to enable staff to appropriately recognize and treat patient’s post-surgical pain. A need was identified to increase nursing knowledge and compliance about pain reassessment documentation in the electronic health record (EHR).

Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia

ABSTRACTElectronic health records are expected to improve the quality of care provided to hospitalized patients. Electronic documentation implementation is a course of action that requires much time and attention. The study aimed to explore and describe the usability and satisfaction of using electronic documentation. Quantitative and descriptive qualitative research methods were done through focus group interviews involving eight nurses and a questionnaire survey to 219 nurses. Satisfaction before and after the implementation of the system was compared using thematic analysis and paired t-test. The system was developed with NANDA, NIC and NOC language and named as "SIMPRO". The results yielded themes on perception about usability, positive and negative responses, barriers to and expectations for successful implementation. SIMPRO was found to increase the nurse satisfaction and usability (p = 0.001). Training on the motives for change might strengthen the nurse's motivation and facilitate the transition to a new system. The study findings implied that electronic nursing documentation was an effective way to improve nursing documentation. In addition, support from the leader and organization might affect the effectiveness of the system implementation

CSII Use in Hospitalized Patients—Adherence to Policy and Safety of Use

Continuous subcutaneous insulin infusion (CSII) therapy is routinely used in diabetes management for patients expecting to use their insulin pumps during hospitalizations. For hospital personnel, this is unfamiliar and complex technology, which necessitates implementing policies and guidelines for standardizing CSII use in the inpatient setting. This study aims to examine adherence to an institutional CSII policy and safety glucometrics for hospitalized patients using CSII. We performed an IRB-exempt retrospective review of CSII user records from January to June 2017. Policy adherence was evaluated for appropriate provider and nurse order set use and documentation in the electronic medical record. 81 patients with 111 admissions on CSII were evaluated. Mean age was 42±16.9 years, 62% were female and 82.7% had type 1 diabetes. Median LOS was 5 days for 788 total patient days, HgbA1c 8.3 ± 1.78, and baseline admission blood glucose (BG) was 175 mg/dL. CSII was continued in 62% of admissions with 12.6% discontinuing use due to medical and surgical contraindications. Overall adherence to the policy was high with documented endocrinology consultations in 100%, provider specified basal rates in 96%, specified bolus doses in 92%, specified correction doses in 83%, specified target BG in 90%, and nurse documented verified doses on the MAR in 93%. Nurse documentation of CSII in the Lines/Drains/Airways flowsheets was 16%. Hypoglycemia (BG<70mg/dL), severe hypoglycemia (BG<40 mg/dL), and uncontrolled hyperglycemia (BG>299mg/dL) were present in 10%, 0.8%, and 10.5% of patient days, respectively. Rates of DKA in CSII users was 0.9%. Policy adherence was effectively achieved for CSII use in hospitals. Rates of hypoglycemia and uncontrolled hyperglycemia were high with very low incidence of severe hypoglycemia or DKA episodes. These results suggest that CSII is possible to safely continue in hospitalized patients, but future studies are necessary to determine how to modify pump rates and optimize glycemic control. Disclosure K. Yang: None. M.B. Ateya: Stock/Shareholder; Self; AbbVie Inc.. R. Gianchandani: None.

Assessing Nurses' Knowledge and Auditing their Practices Regarding Nursing Care Documentation

Background: Nursing documentation is essential for quality of care, which facilitates continuity and individuality of care. Aim of the study: The study was aimed at assessing nurses' knowledge and auditing their practices regarding nursing care documentation. Setting: It was carried out in the medical and surgical units of Mansoura University Hospital. Design: using an analytic cross-sectional design. Subjects: Consisted o f 100 staff nurses and 557 nursing care charts. Tools and procedure: were a self-administered questionnaire and an audit sheet. The fieldwork lasted from April to July 2015. Results: The study revealed that nurses’ age ranged between 20 and 60 years, 77.0% having nursing diploma. 38% of the nurses had satisfactory knowledge about documentation. 18% of the nurses agreed upon the barriers hindering the quality of nursing documentation. Conclusion: the nurses in the study setting have inadequate knowledge about documentation, and minorities of them agree about the barriers hindering quality of documentation. Nurses’ audited practice is low. Recommendations: staff development activities are urgently recommended to improve nurses' knowledge and practice.

Patient Accessible Electronic Health Records: Impacts on Nursing Documentation Practices at a University Hospital.

In a Norwegian health region, patients have online access to their own electronic health record and they can also read the nursing documentation. This paper presents a qualitative study made at a university hospital to investigate how patient accessible electronic health records impact on nursing documentation practices. Semi-structured interviews were made with 12 informants from 5 cardiology departments at one hospital regarding how they used electronic nursing documentation in their daily practice and how they experienced patient accessible nursing documentation. The nurses emphasized that they focused on a clear and well-written nursing documentation, but in some situations, they were hesitant to write sensitive information. The study concluded that the implementation of patients' reading access to the electronic health record had limited impact on the nursing documentation and the daily practice at the departments, but the nursing handover had an even more important function for oral exchange of information.

A Retrospective Study of Non-Ventilator-Associated Hospital Acquired Pneumonia Incidence and Missed Opportunities for Nursing Care.

To determine non-ventilator-associated hospital-acquired pneumonia (NV-HAP) incidence, assess negative impacts on patient outcomes and cost, and identify missed preventive nursing care opportunities. NV-HAP is inadequately studied and underreported. Missed nursing care opportunities, particularly oral care, may aid NV-HAP prevention. This descriptive, observational, retrospective chart review identified adult NV-HAP cases and associated demographic and hospital care data. Two hundred five NV-HAP cases occurred in 1 year at Montefiore Medical Center, equating to an incidence of 0.47 per 1000 patient-days and an estimated excess cost of $8.2 million. ICU transfer following pneumonia occurred in 15.6% of cases. Care requirements from specialist nursing facilities increased at discharge (26.8%), as compared with care requirements on admission (17.6%). Complete nursing care documentation was missing for most patients, with oral care undocumented 60.5% of the time. Preventable NV-HAP cases and their negative impact on cost and patient outcomes may decrease through improved basic nursing care.

LAMA MASA KERJA DAN MANAJEMEN WAKTU DENGAN PELAKSANAAN DOKUMENTASI ASUHAN KEPERAWATAN

<p><em>This hospital has not been optimal in doing nursing care documentation. This study aimed to determine some factors related to nursing care documentation in the Inpatient Room of DR. Achmad Darwis Suliki in 2018. The study desing was a descriptive study analytical approach cros sectional. Total number of samples using a sampling technique is a way of collecting a sample based on the overall population of 42 nurses there. Then, by using total sampling technique, those people were chosen as the samples. The data were collected through questionnaires and observation sheets. The results of this reseach showed that 66.7% of respondents were graduated from Diploma III of Nursing program. Then, 50% of them had less that 3 years working period. Next, 52.4% of the respondents had poor time management. Last, 54.8% of them were not good nursing care documentation. Moreover, there was a correlation between education level (p = 0.037, OR = 5.278), working period (p = 0.013, OR = 6.4) and time management (p = 0.032, OR = 4.952) toward documentation of nursing care. The conclusion of this study is that there is a significant relationship between the length of service of nurse and nursing care documentation. Then, it is expected to all parties, especially the managerial nursing department of Dr. Ahmad Darwis Suliki always improve the performance of nurses in documenting nursing care through nursing training and seminars. <strong></strong></em></p><p><em><strong>Keywords : Working Experiences, Time Management </strong> <strong>of Nursing Care Documentation</strong></em></p><p align="center"><strong><em> </em></strong></p><strong><em></em></strong><strong><em></em></strong>

Avaliação da qualidade dos registros de enfermagem nos cuidados pós-operatórios imediatos

Objetivo: Avaliar a qualidade dos registros de enfermagem nos cuidados pós-operatórios imediatos em unidades de referência no estado dePernambuco. Método: Estudo transversal, descritivo, documental e comparativo com abordagem quantitativa, realizado em três hospitais (A, B, C).A amostra foi composta por 130 prontuários no período de outubro a novembro de 2015 com dados coletados por meio de um formulário semiestruturado.Resultados: Os registros, a checagem e as avaliações dos procedimentos foram feitos de formas diferentes nos hospitais avaliados. No hospitalA não houve registro dos sinais vitais, enquanto nos hospitais B e C, os mesmos foram verificados. Sobre a escala de Aldrete e Kroulik (AK), nasinstituições A e C não houve realização do cálculo em 100% dos casos. As três instituições apresentaram bons resultados, como prontuários legíveise sem a presença de rasuras. Conclusão: Os hospitais analisados não atendem aos padrões preconizados pelas principais literaturas na área de cuidadospós-operatórios quanto aos registros de enfermagem.

Nurses Education and Motivation Towards Nursing Documentation

Introduction: Nursing documentation is an integral part that cannot be separated from healthcare as a responsibility and accountability of nurses. High education and motivation are needed to achieve good nursing documentation. The aim of this study was to know the correlation between education and motivation of nurses towards Intensive Care nursing documentation.Methods: The design used was an analytical survey with a cross-sectional approach. The population was nurses in intensive care of Palembang BARI Hospital with as many as 46 nurses and 44 samples obtained with total sampling. Data were collected by questionnaire and observational and were analyzed by Chi-Square. Independent variables are education and motivation of nurses and the dependent variable is nursing documentation.Results: There was a correlation between education (p=0.035) and motivation (p=0.040) of nurses towards nursing documentation.Conclusion: High education and motivation of nurses influenced towards the quality of nursing education. The nursing manager of the hospital is recommended affording the opportunity to support human resources in the hospital, especially for nurses to participate in education, in accordance with the demands of legislation in nursing education, and to organize the training of nursing documentation.

Should I Unplug the Phones Again: Understanding Government Hospice Audits and “Pre-Tecting” Your Organization Through Robust Provider Documentation (TH303)

•Describe 3 common legal avenues federal and state investigators and Medicare contractors use to target hospice organizations.•Discuss commonly encountered barriers to adequate nursing documentation in hospice care.•Demonstrate 4 evidence-based tools useful for supporting prognosis in patients near the end of life. Since the inception of the Medicare Hospice Benefit, hospice has grown to serve over 1.6 million people per year at an annual cost of over $15.8 billion dollars. This high price tag has led to increased scrutiny by federal and state regulators over the past decade. Documentation by bedside and interdisciplinary team clinicians represents the vast majority of data in these inquiries. Unfortunately, nurses, nurse practitioners, and physicians have been trained to document clinically relevant information without always understanding the impact that this documentation will have during payer audits sometimes years later. How can hospice clinicians further not only their clinical information needs but also protect the organization should an audit occur in the future? In this concurrent session, a healthcare law attorney with 25 years of healthcare and hospice experience will partner with a hospice's nurse manager and 2 HPM physicians who have reviewed hundreds of thousands of pages of hospice records under government audit to share strategies to support effective documentation of eligibility. The False Claims Act and hospice-focused program integrity initiatives will be examined and the role of recovery audit contractors (RAC) and zone program integrity contractors (ZPIC) will be presented. Our nursing leader will address barriers to effective nursing documentation, which constitutes the vast majority of clinical information, including difficulties with technical Local Coverage Determinations, struggles around complex prognostication, and limitations inherent to hospice electronic medical record systems. During the second half of the interdisciplinary presentation, the physician team will present 4 evidence-based tools and articles that cut across disease states that will inform prognostic abilities of physicians completing Certification of Terminal Illness (CTI) documentation and support their prognostic claims. They will use examples from real cases showing well- and poorly written face-to-face and CTI notes, reworking those with opportunities for improvement using the presented tools to reinforce audience learning.

Analysis of Nursing Behavior Factors in Documentation of Nursing Care in Emergency Unit Using Theory of Planned Behavior

The complicacy of emergency unit (EU) working environment will certainly affect the quality of health care, including inaccurate or incomplete documentation. Incomplete nursing documentation indicates that nursing care process is not working properly and continuously. Theory of Planned Behavior (TPB) has been widely used to describe nurse’s behavior and identify important factors that in fl uence them. The purpose of this study is to analyze factors related to nurse behavior in documenting nursing care in EU using TPB. The research is designed as observational analysis with cross sectional approach. Sample is emergency nurses at EU of Level II Hospital Dr. Soepraoen, Panti Waluya Sawahan Hospital, and Islamic Hospital. Sample of 45 Emergency Nurses and 341 documents were selected according to inclusion and exclusion criteria. The result of statistical analysis of partial least square shows that there is a signi fi cant correlation between attitude and intention, perceived behavioral control and intention, and intention and nursing documentation behavior, evidenced by each value of T-Statistic equal to >1.68. Conversely there is no relationship between subjective norms and intention in documenting nursing care and evidenced by the value of T-Statistics

Perbedaan Kepuasan Perawat dalam Pendokumentasian Asuhan Keperawatan Berbasis Komputerisasi dan Manual (Studi di RS Paru dan RS Baladhika Husada Kabupaten Jember) (The Different of Nursing Satisfaction by Computerized Nursing Documentation and Manual Nurs

Nursing documentation is the important thing that must be done by a nurse. There are two kind ofnursing documentation, computerized nursing documentation and manual nursing documentation.This research purposes to find out the different of nursing satisfaction by computerized nursingdocumentation and manual nursing documentation. Crosssectional design was used in thisresearch. Sampling technique used simple random sampling. Total of sample was 30 respondentsand devided by 2 groups who used computerized nursing documentation and who used manualnursing documentation. Data was analyzed by Mann Whitney. The result showed nurse who usedcomputerized nursing documentation have very satisfactied category (100%). Nurse who usedmanual nursing documentation have very satisfactied category (100%). The result of statisticanalyze showed that p Value (1.000)>alpha (0.05), that means there wasn’t differences of nursingsatisfaction by computerized nursing documentation and manual nursing documentation (study inParu Hospital and Baladhika Husada Hospital Subdistrict at Jember). The reason why nursingsatisfaction by manual nursing documentation have very satisfactied category, because it couldease in used of than computerized nursing documentation.Keywords: computerized nursing documentation, manual nursing documentation, satisfaction

What is the problem with nursing documentation? Perspective of Indonesian nurses

BackgroundNursing documentation reflects the quality in patient care. It promotes effective communication between caregivers. However, although its significance has been discussed in numerous articles, nursing documentation remains problematic in Indonesia. ObjectiveThis research was the first of its kind in Indonesia which aim to identify issues with nursing documentation. MethodA qualitative approach through focus group discussions (FGD) with head nurses and staff was conducted to identify problems that hinder nurses’ abilities to follow proper documentation procedure in an urban hospital in Indonesia. The nurses who have more than one year work experience were recruited through simple random technique. There were 35 participants involved. The open-ended questions regarding the nursing documentation process were administered. The group discussions were held two times on each teams and conducted separately between the head nurses and their staff. The data for this descriptive qualitative study were recognized through content analysis methods. ResultsThe results of the study were captured in three themes: (1) Inadequate supervision for nurses on nursing documentation; (2) Competency issues in documentation; (3) Lack of confidence and motivation on documentation. ConclusionEducation is amongst the top listed contributing factors for quality nursing documentation. This is confirmed with this research. The findings of the study suggest the need for continuous support and educational intervention to ensure adherence to the nursing documentation procedure.

Developing the Clinical Supervision Model based on Proctor Theory and Interpersonal Relationship Cycle (PIR-C)

The documentation of nursing care is very important since it is a proof that nurses have taken care of the patients. That’s the reason why there’s a need to develop methods to increase the complete and qualified nursing care documentation. One of the methods is clinical supervision. The clinical supervision model based on the Proctor theory and interpersonal relationship cycle (PIR-C) is developed as an effort to increase the quality of the nursing care documentation in the ward rooms, with the aim of developing a clinical supervision model based on the PIR-C. It is hoped that this model can increase the quality of nursing care documentation. Method: The design of this research used the explanative research with cross sectional approach with 55 selected respondents using purposive sampling. Questionnaire and observation were used as the instrument. To find out the influencing factors toward the implementation of clinical supervision model based on the PIR-C, the Partial Least Square (PLS) was used. The individual factor (path coefficient = 0.274, p value = 0.003) gave significant influence toward the implementation of the clinical supervision model based on PIR-C, the organizational factor (path coefficient = 0.438, p value = 0.00) gave significant influence toward the implementation of the clinical supervision model based on PIR-C, and the work characteristic factor (path coefficient = 0.369, p value = 0.00) gave significant influence toward the implementation of the clinical supervision model based on PIR-C. The individual, organizational, and work characteristic factors are very important factors in the implementation of the clinical supervision model based on PIR-C.

Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative.

This paper reports on a quality-improvement project to develop nursing documentation that reflects holistic care within a specialist palliative centre. The World Health Organization definition of palliative care includes impeccable assessment and management of pain and other symptoms. However, existing nursing documentation focuses mainly on the management of physical symptoms, with other aspects of nursing less frequently documented. Supported by a project team and expert panel, cycles of review, action and reflection were used to develop a new palliative nursing documentation. The project was divided into three phases: audits of existing nursing documentation, development of a new palliative nursing care document and audit tool, and pilot implementation and audit of the new nursing documentation. The new palliative nursing care document demonstrated a higher level of compliance in relation to nursing assessments and a more concise, accurate and comprehensive approach to documenting holistic nursing care and recording of patients' perspective. This project has enabled the consistent documentation of holistic nursing care and patients' perspectives; however, continuous education is necessary in order to sustain positive results and ensure that documentation does not become a 'tick box' exercise. Organisational support is required in order to improve documentation systems.

Point prevalence survey of indwelling urinary catheter use and appropriateness in patients living at home and receiving a community nursing service in Ireland.

Indwelling urinary catheters (IUC) are reported as the most common indwelling device in hospitals and residential/care home settings. The aim of this study was to assess the prevalence and appropriateness of IUCs in people living at home and receiving a community nursing service. An IUC self-report questionnaire was sent to 66 community nurses in one community care area. A second questionnaire was completed by the researcher on each patient (n = 80) identified by the community nurses. Data were analysed using descriptive statistics and the chi-square test was used to test associations between patient demographics, catheter changes and nurses documentation. The self-report questionnaire was completed by 46 of the 52 areas (88% response rate). The overall prevalence of IUCs was 1.9% with a higher prevalence among men (70%) and in the over-85-years age group (31%). The mean age was 76 years (age range = 34-98 years) and duration of use was approximately four years. Routine IUC changes were carried out by community nurses (52%), in the acute hospital (25%) or by general practitioners (20%) and the type of catheter influenced person/location of catheter changes (P = 0.001). This study adds to the understanding of IUCs in patients at home and is the first to investigate if the IUC is appropriate in this setting. It prompted a review of current guidance and development of standard documentation for IUC management locally to ensure that the IUC in use is appropriate. It also suggests that there is a need for internationally accepted, appropriate indications for long-term IUC use to facilitate consistency and allow comparison across studies in future.

THE EFFECT OF PEER REVIEW ON EFL STUDENTS’ WRITING SKILL IN WRITING “NURSING CARE DOCUMENTATION

This study concerns on the effect of peer review on EFL students’ writing skill in writing nursing care documentation. The aims of this study are to investigate the possible effectiveness of the peer review technique to increase the quality of nursing students’ writing skill and to see whether this method motivates student to write. The method of the study is quantitative method. The participants were 78 nursing students in the fourth semester of CendekiaUtama Health College. They were randomly categorized into two experimental and control groups. In the experimental group were providing with an additional peer review instruction offered by O’Muirheartaigh (1990) including the provision of constructive feedback to their peers and evaluating and correcting the peer’s performances. They were paired for peer review, conferencing and exchanging their Nursing care documentation with those of their peers. The reviewers had to correct, evaluate and respond those Nursing care documentation. While, in the control group were traditionally handled by teacher who assigned them homework and correct their Nursing care documentation by themselves.The experiment was run over two month. The data were collected using questionnaire, pre – test and post – test for language proficiency and writing skill, peer response sheet, writing criteria and guidelines sheet.
 The result of the study indicated that p-score is 0,000 <0,05, So that Ho is Rejected and Ha is Accepted which means there is difference of Pre Test with Post Test score. It is known that statistic t - arithmetic is -6.202 which means the score of pre - test is smaller than post - test with point score 6.202. It indicated that the writing of the students in the experimental group improved more than those in control group. Also, those engaged in peer review method were motivated to write more and enjoy writing. It was concluded that peer review provides learners with an authentic audience, increase the students’ motivation for writing and enables them to receive different views on their writing.
 Keywords: Peer Review, EFL Students, Writing Improvement, Nursing care documentation

Post discharge issues identified by a call-back program: identifying improvement opportunities

ABSTRACTObjectives: The period following discharge from the hospital is one of heightened vulnerability. Discharge instructions serve as a guide during this transition. Yet, clinicians receive little feedback on the quality of this document that ties into the patients’ experience. We reviewed the issues voiced by discharged patients via a call-back program and compared them to the discharge instructions they had received.Methods: At our institution, patients receive an automated call forty-eight hours following discharge inquiring about progress. If indicated by the response to the call, they are directed to a nurse who assists with problem solving. We reviewed the nursing documentation of these encounters for a period of nine months. The issues voiced were grouped into five categories: communication, medications, durable medical equipment/therapies, follow up and new or ongoing symptoms. The discharge instructions given to each patient were reviewed. We retrieved data on the number of discharges from each specialty from the hospital over the same period.Results: A total of 592 patients voiced 685 issues. The numbers of patients discharged from medical or surgical services identified as having issues via the call-back line paralleled the proportions discharged from medical and surgical services from the hospital during the same period. Nearly a quarter of the issues discussed had been addressed in the discharge instructions. The most common category of issues was related to communication deficits including missing or incomplete information which made it difficult for the patient to enact or understand the plan of care. Medication prescription related issues were the next most common. Resource barriers and questions surrounding medications were often unaddressed.Conclusions: Post discharge issues affect patients discharged from all services equally. Data from call back programs may provide actionable targets for improvement, identify the inpatient team’s ‘blind spots’ and be used to provide feedback to clinicians.

Step Up & Be Counted! Strategies for Data Collection.

Step Up & Be Counted! (Step Up!) is an innovative project to collect nationally standardized data from the daily documentation of school nurses throughout the United States. Step Up! provides the standardization needed to promote an "apples to apples" analysis of school health resources, interventions, and outcomes across the United States. While some states have collected data for decades and have an effective infrastructure in place, other states are new to data collection and are creating processes to support data collection. Designated State Data Champions have volunteered to collect aggregated de-identified data from school districts throughout their state. The following is a discussion of some of the data collection innovations shared by Designated State Data Champions at the 2017 NASN Annual Conference.

Outcome Calculations Based on Nursing Documentation in the First Generation of Electronic Health Records in the Netherlands.

Previous studies regarding nursing documentation focused primarily on documentation quality, for instance, in terms of the accuracy of the documentation. The combination between accuracy measurements and the quality and frequencies of outcome variables such as the length of the hospital stay were only minimally addressed. An audit of 300 randomly selected digital nursing records of patients (age of >70 years) admitted between 2013-2014 for hip surgery in two orthopaedic wards of a general Dutch hospital was conducted. Nursing diagnoses: Impaired tissue perfusion (wound), Pressure ulcer, and Deficient fluid volume had significant influence on the length of the hospital stay. Nursing process documentation can be used for outcome calculations. Nevertheless, in the first generation of electronic health records, nursing diagnoses were not documented in a standardized manner (First generation 2010-2015; the first generation of electronic records implemented in clinical practice in the Netherlands).