Nursing Documentation Research Articles

Delirium superimposed on dementia in post-acute care: Nurse documentation of symptoms and interventions

Delirium superimposed on dementia (DSD) is common in older adults being discharged to post-acute care settings (PAC). Nurse documentation remains poorly understood. Aims were to describe nurse documentation and to determine associations in a secondary data analysis of a large, single-blinded randomized controlled trial (Recreational Stimulation For Elders As A Vehicle To Resolve DSD (Reserve For DSD). Just under 75% of the sample had at least one symptom of delirium documented by the nursing staff, while 25.9% had none despite being CAM positive by expert adjudication. Only 32% had an intervention documented. Number of documented interventions were significantly associated with number of documented symptoms. There is a need for research and innovation related to nurse documentation and communication of DSD symptoms and interventions in an efficient and accurate manner to impact care for vulnerable older adults in these settings.

Connection Motivation Work Nurse With Accuracy Charging Documentation Care Nursing at Sundari Hospital Medan

Accuracy in filling out nursing care documentation is important in nursing services, because it will provide legal protection for both the giver and the recipient. Nursing care will reflect the quality of nursing care. The accuracy of filling nursing care documentation is influenced by motivation. From the results of the study the standards of nursing care applied were taken from 30 patient statuses. Can be taken the result of 61.5%. Who performs the standard nursing care that is applied. This study aims to determine the relationship between the work motivation of nurses and the accuracy of documentation of nursing care in the living health care installation at the Sundari Hospital in Medan. This type of research is quantitative descriptive with a cross sectional approach. Samples for the motivation of nurses were taken from 4 living medical care units with a total sample of 30 respondents, and for the accuracy of filling out nursing care documentation, quota sampling was taken. Data was taken using a questionnaire, for the accuracy of filling out nursing care documentation using the ASAK instrument from the Ministry of Health 1997. To determine the relationship between two variables, the Product Moment Correlation Test was carried out with the results of rxy = 0.474 and p = 0.008, which means that there is a significant relationship between nurses' work motivation. with the accuracy of filling out nursing care documentation in the inpatient room at Sundari Hospital Medan.

Automated documentation of almost identical movements in the context of dementia diagnostics

When monitoring the health state of people with neurological diseases, it is crucial to detect disease progression and disease-related changes as soon as possible. Such changes can be detected in the performance of everyday activities like eating, drinking, nose blowing, reading, looking at photos, knitting, telephoning, or brushing hair. In order to supervise such everyday activities, this work proposes an approach employing smartwatches in combination with a Recurrent neural network. A smartwatch offers the possibility of integrating sensor technology into a patient’s daily routines in a unobtrusive way. We have developed a machine learning web tool to track motion data using smartwatch sensors. Data from the accelerometer, heart rate sensor, gyroscope, gravity sensor and position sensor are tracked at 20 Hz. Our tool allows a systematic comparison of the performance between a Long Short-Term Memory (LSTM) model and the different sensor systems in classifying twelve nearly identical daily activities. In this paper, we address the problem of caregiver effort in creating daily care documentation for dementia patients. We present an activity classification system that enables automatic classification of daily activities of patients with dementia across a nursing shift. To assist caregivers, we provide an idea for integrating our system into a nursing documentation. • When monitoring the health state of people with neurological diseases, it is crucial to detect disease progression and disease-related changes as soon as possible. Such changes can be detected in the performance of everyday activities like eating, drinking, nose blowing, reading, looking at photos, knitting, telephoning, or brushing hair. • In order to supervise such everyday activities, this work proposes an approach employing smartwatches in combination with a Recurrent neural network. A smartwatch offers the possibility of integrating sensor technology into a patient’s daily routines in a unobtrusive way. • We have developed a machine learning web tool to track motion data using smartwatch sensors. Data from the accelerometer, heart rate sensor, gyroscope, gravity sensor and position sensor are tracked at 20 Hz. • Our tool allows a systematic comparison of the performance between a Long Short-Term Memory (LSTM) model and the different sensor systems in classifying twelve nearly identical daily activities. • In this paper, we address the problem of caregiver effort in creating daily care documentation for dementia patients. We present an activity classification system that enables automatic classification of daily activities of patients with dementia across a nursing shift. To assist caregivers, we provide an idea for integrating our system into a nursing documentation.

Knowledge and Attitude of Nurses with Computerized Based Nursing Care Documentation

The completeness of the implementation of nursing care documentation is part of the quality of services in hospitals that are influenced by the knowledge and attitude of nurses. This study aims to identify the relationship between the knowledge and attitudes of nurses with the completeness of computerized-based nursing care documentation. This research is quantitative research with a descriptive correlation design and cross-sectional approach. The research population were a nurse at the inpatient unit and outpatient unit of Hospital X North Jakarta. The samples used were purposive techniques with 121 respondents. Univariate analysis of nurse knowledge obtained fewer knowledge data with 40 respondents (33.1%) knowledge of 10 respondents (8.3%) and good knowledge of 71 respondents (58.7%) for attitudes, nurses had less attitude with 57 respondents (47.1%) and good attitude of 64 respondents (52.9%). The results of bivariate research show that: there is a meaningful relationship between the knowledge and attitude of nurses with the completeness of documenting computerized-based nursing care at Hospital X North Jakarta, namely knowledge (p value= 0.000) and attitude (p-value = 0.000). The advice in this study is the improvement and development of training for nurses in implementing computerized-based nursing care documentation. So that the development of science from nurses on computerized-based documentation can be carried out properly.

The Influence of the Design of Nursing Care Documentation Design SDKI, SLKI, SIKI (3S) in Hospital Management Information Systems on Nurse Satisfaction at Dian Harapan Jayapura Hospital

The Service is required to be part of the hospital in implementing the documentation of nursing care using computerization. Patients in hospitals often feel dissatisfied with services because nurses take too long to search for patient history data and nurses feel dissatisfied in paper-based documentation which makes the workload increase. The purpose of this study was to design a nursing care documentation design in the 2000s SDKI, SLKI, SIKI (3S) in hospital management information systems on nurse satisfaction. The research method used a research and development design as well as descriptive observational cross sectional with a total sampling technique of 74 nursing respondents at Dian Harapan Jayapura Hospital and analyzed using simple regression analysis. The results showed that 73% of the 3-S nursing care documentation design in SIMRS was in the good category and 77% of nurses were satisfied with the 2000s nursing care documentation design in SIMRS and a significant p-value (0.000) which means that there is an effect of 30.8 % between the design of the 3S nursing care documentation in SIMRS and the satisfaction of nurses at Dian Harapan Jayapura Hospital. It can be said that by increasing the resulting information system, the satisfaction of nurses as users is getting better. It is recommended to hold socialization, training and policy realization for nurses documenting 3S nursing care in SIMRS.

Bundled Approach to Improve Inpatient Stroke Recognition and Time to Treatment.

BACKGROUND: Early recognition of inpatient stroke is critical in reducing poor outcomes. A gap in knowledge and recognition of stroke by nursing staff was observed; protocols did not incorporate the Balance, Eyes, Face, Arms, Speech, and Time (BE-FAST) symptom mnemonic, and code stroke documentation was frequently incomplete. PURPOSE: This initiative aimed to improve timely recognition, evidence-based treatment, and nursing documentation of stroke-related symptoms. METHODS: This quality improvement initiative implemented an inpatient nurse-driven code stroke bundle. A pre-post prospective intervention design was implemented over 3 months. Code stroke bundle components included an evidence-based protocol, algorithm, visual aids, and education. Nursing communication and documentation used the BE-FAST mnemonic in a Situation, Background, Assessment, Recommendation format. RESULTS: Nursing stroke knowledge improved 8% (88% vs 96%, P < .001); stroke response times improved 15 minutes (25.9 vs 11 minutes, P = .383), although not significant; the code stroke documentation completion rate was increased 48.1% (0 [0%] vs 13 [48.1%], P < .001); and improved utilization of the BE-FAST tool with Situation, Background, Assessment, Recommendation communication (0 [0%] vs 20 [47.6%], P = < .001) was observed. The code stroke cancelation rate slightly worsened (10 [26.3%] vs 14 [26.9%], P = .949), code stroke notifications for altered mental status improved (15 [39.5%] vs 8 [15.7%], P = .015), and the stroke mimic rate improved (27 [71.1%] vs 35 [67.3%], P = .708). CONCLUSION: Nurses provide hospital patient care continuously and are in a key position to intervene when patients present changes in symptoms. Through education and creating an evidence-based protocol, nurses can impact patient outcomes in early recognition and activation of the code stroke system. Further studies are warranted to refine strategies leading to continued improvement in early stroke identification.

The Influence of the Application of Digital-Based Nursing Documentation on the Quality of Nursing Services

Digital or Electronic-Based Nursing Documentation (END) is now regarded as a fitness precedence in many international locations around the world. However, the evidence for the effectiveness of electronic-based nursing documentation in health care is still uncertain. This overview targets to evaluate the literature systematically on the outcomes of END interventions in merchandising or enhancing the high-quality of care. Three databases, Google Scholar, PubMed, and Ebscohost, were used to extract the applicable articles. The articles were selected primarily based on inclusion standards and observed the favored reporting framework for the Systematic Review and Meta-Analysis (PRISMA) framework for an imperative assessment of every article. The key phrases used were Electronic Documentation or Electronic Nurse Documentation and Quality of Care in the primary search in every article title, and finally, the criteria for inclusion and deletion were met by 7 articles. According to the findings of a systematic review, there is little proof that using END interventions may raise or improve the standard of care in nursing environments. Based on the outcomes of the learn about that has been carried out, it can be concluded that the tremendous effect on utility of this digital nursing recording gadget can enhance the satisfaction of nursing care and the efficiency and protection of affected person data.

Efektifitas Pelatihan Asuhan Keperawatan pasien Kanker Payudara dalam Penerapan SDKI, SLKI, dan SIKI

Nursing documentation is the most important part of providing nursing care given by nurses to patients, especially for breast cancer. This community service activity is aimed at increasing the knowledge of nurses in providing nursing care and documenting by the guidelines from the Indonesian National Nurses Association (PPNI), namely 3S: Indonesian Nursing Diagnosis Standards (IDHS), Indonesian Nursing Outcomes Standards (SLKI) and Indonesian Nursing Intervention Standards (SIKI). ). This training is provided online, which begins with a pre-test, then lectures and discussion/problem-based solving followed by a post-test. Participants in this training were all student nurses and nurses with a total of 285 participants. The results of this training found an increase in knowledge of the application of the 3S covering signs and symptoms, diagnoses, interventions, and outcomes. It is hoped that from the results of this activity nurses have started to implement nursing care and document it using this 3S.

Documentation Burden in Nursing and Its Role in Clinician Burnout Syndrome.

The purpose of this study is to understand the relationship between documentation burden and clinician burnout syndrome in nurses working in direct patient care. The Office of the National Coordinator considers documentation burden a high priority problem. However, the presence of documentation burden in nurses working in direct patient care is not well known. Furthermore, the presence of documentation burden has not been linked to the development of clinician burnout syndrome. This paper reports that the results of a cross-sectional survey study comprised of three tools: (1) The burden of documentation for nurses and mid-wives survey, (2) the system usability scale, and (3) Maslach's burnout inventory for medical professionals. Documentation burden has a weak to moderate correlation to clinician burnout syndrome. Furthermore, poor usability of the electronic health record (EHR) is also associated with documentation burden and clinician burnout syndrome. This study suggests that there is a relationship between documentation burden and clinician burnout syndrome. The correlation of poor usability and domains of clinician burnout syndrome implies the need for more work on improving the usability of EHR for nursing documentation. Further study regarding the presence of documentation burden and its correlation to clinician burnout syndrome should focus on specific areas of nursing to understand the drivers of documentation burden variation within and across specialty domains.

“A STUDY TO ASSESS THE PRACTICES OF STAFF NURSES RELATED TO NURSING DOCUMENTATION AMONG THE STAFF NURSES OF MMIMS&amp;R, MULLANA, AMBALA, HARYANA.”

Nursing is a profession that requires specialized skill and knowledge pertinent to the duties to be executed. There is currently considerable interest throughout the world within the health care sector to increase the quality of nursing documentation and nursing terminology. The present study was conducted to assess the practices of staff nurses regarding nursing documentation. In this study 150 sample of the nurses who are working in the ICUs and CCU at MMIMS&amp;R Hospital was collected by purposive Sampling technique. Data was collected through Structured Observational Checklist.The result of study showed that mean percentage of patient profile is (99.16%), general consideration is (97.14%) and need based care is (76.33%). Mean±SD of patient profile is (11.9) ±(0.55). Vital sign (10.60) ±(2.06) general consideration(6.8) ±(0.7) and the mean of the practices of staff nurses regarding nursing documentation was 61.99+- 8.30 with median of 65 and mode was 70. Further In relation to area of work and work experience significant association was seen with the practice of staff nurses as p value &lt;0.05. The study concluded that Staff Nurses had good practices (75.59) regarding nursing documentation followed by poor practices (24.41%).

“A STUDY TO ASSESS THE PRACTICES OF STAFF NURSES RELATED TO NURSING DOCUMENTATION AMONG THE STAFF NURSES OF MMIMS&amp;R, MULLANA, AMBALA, HARYANA.”

Nursing is a profession that requires specialized skill and knowledge pertinent to the duties to be executed. There is currently considerable interest throughout the world within the health care sector to increase the quality of nursing documentation and nursing terminology. The present study was conducted to assess the practices of staff nurses regarding nursing documentation. In this study 150 sample of the nurses who are working in the ICUs and CCU at MMIMS&amp;R Hospital was collected by purposive Sampling technique. Data was collected through Structured Observational Checklist.The result of study showed that mean percentage of patient profile is (99.16%), general consideration is (97.14%) and need based care is (76.33%). Mean±SD of patient profile is (11.9) ±(0.55). Vital sign (10.60) ±(2.06) general consideration(6.8) ±(0.7) and the mean of the practices of staff nurses regarding nursing documentation was 61.99+- 8.30 with median of 65 and mode was 70. Further In relation to area of work and work experience significant association was seen with the practice of staff nurses as p value &lt;0.05. The study concluded that Staff Nurses had good practices (75.59) regarding nursing documentation followed by poor practices (24.41%).

HUBUNGAN PENGETAHUAN DENGAN KELENGKAPAN PENGISIAN DOKUMENTASI ASUHAN KEPERAWATAN BERDASARKAN PENDEKATAN PROSES KEPERAWATAN MAHASISWA KEPERAWATAN SEMESTER VI STIKES BUANA HUSADA PONOROGO

Knowledge is the process of finding information obtained by a person through various sensory organs. Knowledge in this case relates to the completeness of the nursing care documentation. The nursing process as a tool for nurses to carry out nursing care carried out on patients has an important meaning for both parties, namely nurses and clients. The purpose of this study is to analyze knowledge with completeness of filling in nursing care documentation based on the approach of the nursing process of nursing students in semester VI of STIKES Buana Husada Ponorogo. This study used a correlational design . The population in this study was all nursing students in semester VI of STIKES Buana Husada Ponorogo. The sample in this study was all 15 nursing students in semester VI of STIKES Buana Husada Ponorogo. The sampling technique is Total sampling. This study used the Spearman Rank statistical test with α = 0.05. The results of research from 15 respondents showed that student knowledge about nursing care documentation based on the nursing process approach was mostly good as many as 9 respondents (60%), students in documenting nursing care with the nursing process approach were mostly complete as many as 8 respondents (53.3%). There is a Relationship between Knowledge and Completeness of Filling in Nursing Care Documentation Based on the Nursing Process Approach of Nursing Students in Semester VI STIKES Buana Husada Ponorogo.with p value = 0.000 with α = 0.05 Respondents always update the latest science related to nursing care in order to be able to compile nursing care in a comprehensive and orderly manner in accordance with the development of science.

Documentation for Assessing Pain in Postoperative Pain Management Pre- and Post-intervention

PurposeAlthough Norwegian law requires the documentation of patients’ care processes, including pain assessment, research has shown that the quality of postoperative documentation for assessing pain does not meet an acceptable standard and requires improvement. The purpose of this study was to investigate whether an educational intervention can increase nurses’ documentation of postoperative pain assessments, alter patients’ opioid consumption, and ensure that patients have at least one documented Numeric Rating Scale (NRS) ≤3 at rest before being discharged. A secondary aim was to investigate whether the nurses’ education and experience influenced their pain assessments. DesignAn observational study with a pre-post intervention. MethodsThe study following a pre-post design involved documenting pain assessments of 304 patients undergoing cancer surgeries in a postoperative unit at the Norwegian Radium Hospital, Oslo University Hospital. In an educational intervention, two 45-minutes teaching sessions within two weeks, addressed validated pain assessment tools and the documentation of pain assessment. Descriptive frequency analysis and partial correlation with Pearson's r - value were used, with P < .05 indicating significance. FindingsPostintervention, pain assessments in general increased significantly from a mean of two times per patient to three times. Overall, the use of assessment tool Critical -Care Pain Observation Tool increased from 6.1% to 25.8%, opioid consumption increased in mean from 3.34 to 4.79 in milligram and the documentation at discharge increased from 81.4% to 91.4%. The documentation of nurses with more than 10 years’ experience in the unit especially improved from 17.5% to 31.7%. ConclusionsEducational intervention and reminders about basic systematic pain assessment and the evaluation of pain measures improved nurses’ documentation of postoperative pain management and documentation at discharge. The findings underscore the importance of regularly ensuring the quality of patients’ treatment by systematically documenting nurses’ clinical tasks and the outcome of patients’ care.

Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program.

Introducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite "big-bang" EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care. Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation. The Model for Improvement quality improvement framework guided cycles of "Plan, Do, Study, Act." Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps. Analysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance. This work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.

Optimalisasi Penyusunan Dokumentasi Asuhan Keperawatan bagi Perawat Kalimantan Barat

Nursing is a profession for health workers to maintain the quality of health services. The nursing profession makes efforts to develop professional service quality, one of which is regarding nursing care standards, namely documentation. Quality documentation is handy for hospitals in increasing accreditation, communication between professions, indicators of quality services, and a research facility. Nursing documentation, one of them is that diagnosis is an essential aspect of nursing practice. Standard Diagnosis Keperawatan Indonesia, Standart Luaran Keperawatan Indonesia, and Standard Intervensi Keperawatan Indonesia have been compiled by the PPNI professional organization and are expected to improve the quality of Indonesian nursing care documentation. Therefore, there is a need for comprehensive socialization for nurses; the activities carried out were attended by 210 nurses and conducted virtually through zoom meetings. During the activity, pretest and posttest were carried out to determine participants' level of knowledge about SDKI. From the results of the tabulation of participants, it was found that most of the participants were educated professional nurses (70%) and primary nurses (51.90%). The results of the analysis of the results of the pretest-posttest obtained a p-value = 0.000, which indicates a significant difference in nurses' knowledge. The results of this pretest-posttest show that nurses' knowledge can be increased by providing socialization of nursing diagnosis standards. It is expected that hospitals can routinely provide knowledge stimulation, especially about nursing care documentation.

Hubungan Pengetahuan dan Sikap terhadap Kinerja Perawat dalam Pendokumentasian ASKEP di RSUD I Lagaligo Wotu

Nursing documentation is a permanent record of what happened to the client. Apart from being an accreditation requirement which is a legal requirement in health services (Doenges, 2013). One of the functions of documentation for nurses is as a means of communication and evidence of accountability for the implementation of care activities (Ministry of Health of the Republic of Indonesia, 2013). To find out the relationship between knowledge and attitudes towards nurse performance in documenting nursing care at RSUD I Lagaligo Wotu in 2021. The research design used is an analytical survey with a correlational type of study. The approach used in this study was a cross-sectional approach with a total of 84 nurses and sampling using accidental sampling techniques. Data collection using questionnaires and data processing using the SPSS 22.0 program presented in the form of tabels and narratives. The analysis carried out is univariate and bivariate with a meaningfulness level of α = 0.05. The results of the data analysis obtained that there was a relationship between knowledge and the performance of nurses in the completeness of documenting nursing care at RSUD I Lagaligo Wotu.

Hubungan Antara Beban Kerja Perawat dengan Motivasi Pelaksanaan Dokumentasi Asuhan Keperawatan di Irna I RSU Dr Saiful Anwar Malang

The high number of COVID-19 cases in December 2020 caused 3,233 people to be infected. 303 of those people underwent treatment at the dr. Saiful Anwar Malang Public Hospital as a COVID-19 referral hospital. As a result, this phenomenon caused a surge in bed occupancy capacity of 85%-100%, so that it increased the nurse workload. This research aimed to understand the relationship between the nurse workload and the motivation to implement nursing training documentation at IRNA I dr. Saiful Anwar Malang Public Hospital. The research method applied was correlational research with a cross-sectional approach. This method aimed to determine the relationship between the nurse workload and the motivation to implement nursing training documentation. The sample consisted of 55 people who were chosen by total sampling. The variable studied in this research was the nurse workload with the motivation to implement nursing training documentation. The results showed that most of the respondents had a high workload, which was as many as 27 people (67.5%), and the motivation to implement nursing training documentation was primarily high, which was as many as 33 people (82.5%). However, when the workload was very high, and 6 respondents experienced it, the motivation decreased by 12, 5%. The results of Spearman's analysis and statistical test, p = -0.378 at = 0.05, indicated that there was a significant correlation between the variables. The direction of the negative correlation indicated that the higher the workload of nurses, the lower the motivation in conducting nursing training documentation. Therefore, it is necessary to balance the availability of nurses and the workload so that the quality of the nursing services can be reached.

Neonatal electronic resuscitation app documentation (NeRD): Electronic documentation compared to written documentation

BackgroundAt present, neonatal resuscitations are documented on the Neonatal Emergence Record, but thorough completion of this record in resuscitations, on average, is poor and less than adequate for proficient, safe and legal documentation. Failure of an accurate representation of a full resuscitation, in real time, can have a bearing on the clinical care given, for example in hypoxic infants. ObjectivesThe objective is to improve documentation of resuscitation, ensuring accurate, contemporaneous and complete documentation of neonatal resuscitation in real time. MethodsA pilot study evaluated the feasibility, time, cost, adverse events and effect size (statistical variability) to predict an appropriate sample size and improve upon the study design prior to the performance of a full-scale study.Twenty neonatal participants were enrolled in the pilot study. The sequence of randomization was computer generated and blinded to each resuscitation team. ConclusionThe NeRD app achieved higher levels of task completion for majority of the audit criteria. Although only a small study the NeRD app allowed for more accurate and contemporaneous documentation when compared to the current paper-based documentation. In a time where litigation is high and all medical and nursing documentation are scrutinized, high quality, accurate, contemporaneous documentation will be of value. Therefore, the main pilot study is feasible without changes to the protocol. A larger randomized controlled trial is needed for more robust evidence in the use of the NeRD app in documenting neonatal resuscitation.

1046 STANDARDIZING THE APPROACH TO POSTURAL HYPOTENSION: A QUALITY IMPROVEMENT PROJECT

Abstract Background &amp; Aims Falls in the older population cause significant morbidity and mortality, and can be a catalyst for deconditioning and a decrease in functional baseline. In the long-term, this results in higher levels of care needs and health issues. As orthostatic hypotension is a common cause for falls in the elderly, our QIP aims to develop a standardized approach to postural hypotension assessment. Methodology We undertook two rounds of retrospective data collection on the ward focusing on LSBP as part of the assessment that should be completed on every patient who presents with a fall. In between we undertook an intense period of small group education sessions. We involved a nurse and an HCA in delivering this teaching to ensure sustained change. We also created cards demonstrating the correct technique of doing a LSBP and attached these to all BP machines. Finally, we introduced a midday board round which allowed for more effective communication between the MDT. Results In cycle 1, 26% of patients presenting with a fall had a LSBP done prior to discharge whilst in cycle 2, 56% of patients did. We significantly improved the technique and documentation on our electronic system from 0% in the first cycle to 95% in the second. However, this increase in LSBP comes from increased nursing staff completion and documentation as opposed to more doctors requesting a LSBP as part of the falls assessment, with only 63% of patients having documented requests in both cycles. Conclusion Our results were encouraging but also highlighted further areas for development in this area. Moving forward, we have extended the project to increase doctors’ awareness of the falls assessment. We have presented at the departmental meeting and included multifactorial falls assessment teaching in the induction handbook to allow for sustained change.

Acceptance of electronic and paper-based standardized Nursing Care Plans Documentation System among nurses in a Tertiary Health Facility in North-Central Nigeria

Acceptance is important for successful adoption of new technology. This study assessed the level of acceptability of electronic and paper-based Standardized Nursing Care Plans templates among nurses in a tertiary health facility in North Central Nigeria. Adopting a comparative design, data were collected from 32 nurses working in two medical units of a tertiary health facility who had earlier been introduced to an electronic and Paper-based Standardized Nursing Care plan (SNCPs) templates. A structured questionnaire was used to collect data from the nurses. Data was computed using Statistical Package for Social Sciences (SPSS) version 20 and analyzed using frequency distribution, independent t-test, and Multiple Regression. The result showed that the electronic SNCPs were accepted by all nurses working in the electronic ward while only 2(12.5%) of nurses in the paper word did not accept the paper SNCPs. There was no significant difference in the level of nurses’ acceptability of SNCPs (t-value = 1.400, p = 0.172). Also, only nurses’ years of experience had a statistically significant relationship with acceptance. Providing adequate training would enhance nurses use SNCPs in either electronic or paper formats.