Nursing Process Documentation Research Articles

Nursing Process Documentation among Nursing Students

Nursing Process Documentation among Nursing Students

Correlation between Nurse Motivation and the Quality of Nursing Care Documentation

Introduction: Nursing documentation is evidence of nurses' recording and reporting in providing accurate and complete written health services. Documenting nursing care is quite important. However, there are still many incomplete nursing care documentations written by nurses. The factor that encourages nurses to carry out nursing documentation is the nurse's motivation and supported by rewards from the hospital as appreciation for the nurse's performance. Objective: The purpose of this study was determine the Correlation between Nurse Motivation and the Quality of Nursing Care Documentation. Method: This research is a quantitative study with a correlation study and a cross sectional design. The sampling technique used was random sampling with 66 respondents at RSUD Dr. R. Soedjati Somodiarjo Purwodadi. The data were analyzed by using the chi-square statistical test (X2) and a correlation strength test was carried out using Spearman's (r). Results: Based on the chi-square statistical test (X2), the p value is 0.000. As the results show <0.05, it means that Ha is accepted and Ho is rejected. Then a correlation strength test carried out by using Spearman’s (r) reveals a correlation coefficient or r = 0.086, indicating that there is a strong positive correlation between nurses’ motivation and the quality of nursing care process documentation at RSUD Dr. R. Soedjati Somodiarjo Purwodadi. Conclusion: The results of the study indicate that there is a positive correlation between nurses’ motivation and the quality of the nursing care process documentation at RSUD Dr. R. Soedjati Somodiarjo Purwodadi.

The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study.

To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument. A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument. Low quality levels of nursing process documentation were found. The Q-DIO subscale "Nursing diagnoses as process" (assessment) revealed a mean=1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. "Nursing diagnoses as product" showed inaccurate diagnoses; mean=1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean=0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29). Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for "Nursing diagnoses as process." The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes. This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.

The Role of Nurse Motivation, Competence And Workload for Increasing Completeness of Nursing Process Documentation At Class B Private Hospital In Jakarta

The Role of Nurse Motivation, Competence And Workload for Increasing Completeness of Nursing Process Documentation At Class B Private Hospital In Jakarta

Značaj i primena dokumentacije "proces zdravstvene nege" u kabinetu za endoskopiju

Any systematic and high-quality work in any profession is based on well-designed documentation. In the nursing profession, mistakes and omissions are not allowed precisely because their work is focused on the care of persons who represent a particularly vulnerable category, namely users of health services. In order to implement nursing interventions as efficiently and comprehensively as possible, the implementation of the nursing process is important, which requires a well-organized system of documentation, which is available to all members of the nursing team. The nursing process documentation is a standardized documentation that has been developed, modified and improved since the 1950s. Over time, it has been adapted to meet the needs of different health institutions and health services. The documentation of the nursing process is most often applied in health institutions where secondary and tertiary health care is provided, as well as in work with students of academic institutions of the health profession. Documentation of the nursing process in the Republic of Serbia is rarely used in primary health care, and it is also not fully implemented in secondary and tertiary health care institutions. Practical experience confirms that it is most often implemented in departments of internal medicine, while it is rarely used in departments of surgery or radiology, and its implementation is completely omitted in day hospitals and cabinets that are integral parts of these institutions, or in dispensaries of primary health care institutions. Precisely for these reasons, the aim of this paper was to assess the importance and implementation of nursing process documentation in the Endoscopy Cabinet for patients of the Institute of Oncology and Radiology of Serbia.

Quality indicators of the nursing process documentation in clinical practice.

to propose quality indicators for clinical nursing documentation. methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen's kappa. the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services. seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.

Quality of the documentation of the Nursing process in clinical decision support systems

Objective:to compare the quality of the Nursing process documentation in two versions of a clinical decision support system.Method:a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics.Results:the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated.Conclusion:the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.

Evaluation of Electronic Health Records on the Nursing Process and Patient Outcomes Regarding Fall and Pressure Injuries.

Digitalizing the nursing process has become a trend in medical care. The purpose of this study was to evaluate implementation of the Standardized Computerized Nursing Process Documentation System and patient outcomes. We analyzed hospitalized patients' electronic health record database with a total of 19 659 patients in 2015. The analysis focused on nurses' selection of nursing care plans for patients with a high risk of falls or pressure injuries through admission assessments. The effectiveness of implemented nursing care plans following falls or pressure injuries was explored. The results reveal that 55% of the hospitalized patients had a risk of falling, and 27.85% of patients were at risk of pressure injuries. Patients receiving nursing care plan who experienced falls or pressure injuries were significantly higher than those without a nursing care plan (P < .001). This study could not provide direct evidence for the effect of nursing care plans on reducing the incidence of falls and pressure injuries, which may be attributable to patient characteristics. Furthermore, an analysis on data from 2007 to 2017 using a run chart revealed that the mean incidence rate for pressure injuries decreased, whereas that for falls remained stable. The results indicate that the system did not increase the occurrence of such incidences.

Documentation of the nursing process in public health institutions.

To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health. A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations. Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors. Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.

Clinical Indicators for Evaluation of Outcomes of Impaired Tissue Integrity in Orthopedic Patients: Consensus Study.

To select outcomes from the Nursing Outcomes Classification (NOC) to evaluate impaired tissue integrity in patients undergoing orthopedic surgeries, and develop conceptual and operational definitions for their indicators. A consensus study involving 10 nurses from clinical practice. A 100% consensus was established in the outcomes selection. Wound Healing: Primary intention (1102) with two indicators: (110214) Scar formation, and (110201) Skin approximation were selected. Four indicators were grouped to evaluate inflammatory signs together with foul wound odor and six for drainage. These indicators direct the outcomes evaluation for wound healing. Support to the definition the priority interventions in nursing process documentation.

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 &gt;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).

간호학생의 교육용 전자간호기록 시스템 적용 효과

Purpose This study aimed to identify the effectiveness of educational Electronic Nursing Record System in terms of nursing process preparation ability and satisfaction about the system itself. Methods A one group pre-post experimental study design was utilized in this study. The effectiveness of the system was examined through quality of nursing diagnoses, interventions, and outcomes and electronic nursing record system satisfaction inventory. Junior and senior nursing students were the potential study respondents and evaluation instruments were applied only for the one who agreed to participated in the study. Education about nursing process and electronic nursing record system was carried out as part of regular classes and students were guided to prepare nursing process upon the scenarios developed earlier. Results 29 juniors and 33 seniors prepare nursing process documentation related to each scenario and both groups showed significant improvement upon nursing process documentation (t=7.53, p<.001, t=3.23, p=.003, respectively) compared to paper based nursing process preparation. Satisfaction about system itself was 2.78(0.81). Conclusion Educational electronic nursing record system seems to be effective to train nursing students for nursing process preparation ability. Effort to enhance its utility are called in the area of education and system itself. Keywords: Nursing records, Nursing students, Nursing process, Informatics, Personal satisfaction 주요어: ì „ìžê°„í˜¸ê¸°ë¡, 간호대학생, ê°„í˜¸ê³¼ì • ì ìš©ëŠ¥ë ¥, 이용 만족도

Nursing process documentation: rationale and methods of analytical study.

to describe the methods used to analyze the associations between variables of service, nursing and the nursing process documentation in institutions of the Department of Health of the State of São Paulo. multilevel analytical study with data obtained in the domains of institution, units of the institution and nursing professionals who work there, using standardized instruments. The analyses had as axis the degree of completeness of the nursing process documentation in units or institutions and their association with variables of nursing personnel, of units and of institutions. This study will provide important empirical evidence on the factors involved in the nursing process documentation.

The Effects of a Web-Based Nursing Process Documentation Program on Stress and Anxiety of Nursing Students in South Korea.

To examine the effects of a web-based nursing process documentation system on the stress and anxiety of nursing students during their clinical practice. A quasi-experimental design was employed. The experimental group (n = 110) used a web-based nursing process documentation program for their case reports as part of assignments for a clinical practicum, whereas the control group (n = 106) used traditional paper-based case reports. Stress and anxiety levels were measured with a numeric rating scale before, 2 weeks after, and 4 weeks after using the web-based nursing process documentation program during a clinical practicum. The data were analyzed using descriptive statistics, t tests, chi-square tests, and repeated-measures analyses of variance. Nursing students who used the web-based nursing process documentation program showed significant lower levels of stress and anxiety than the control group. A web-based nursing process documentation program could be used to reduce the stress and anxiety of nursing students during clinical practicum, which ultimately would benefit nursing students by increasing satisfaction with and effectiveness of clinical practicum.

Relationships among NANDA-I diagnoses, nursing outcomes classification, and nursing interventions classification by nursing students for patients in medical-surgical units in Korea.

The purpose of this study was to identify NANDA-I, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC; NNN) linkages used by Korean nursing students during their clinical practice in medical-surgical units. A comparative descriptive research design was used to measure the effects of nursing interventions from 153 nursing students in South Korea. Nursing students selected NNN using a Web-based nursing process documentation system. Data were analyzed by paired t-test. Eighty-two NANDA-I diagnoses, 116 NOC outcomes, and 163 NIC interventions were identified. Statistically significant differences in patients' preintervention and postintervention outcome scores were observed. By determining patient outcomes linked to interventions and how the degree of outcomes change after interventions, the effectiveness of the interventions can be evaluated.

Nursing process documentation systems in clinical routine—prerequisites and experiences

Documentation of the nursing process is an important, but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems, such as low quality and high writing efforts, are reported. However, it is still unclear if computer-based documentation systems can reduce these problems. At the Heidelberg University Medical Center, computer-based nursing process documentation projects began in 1998. A computer-based nursing documentation system has now been successfully introduced on four wards of three different departments, supporting all six phases of the nursing process. The introduction of the new documentation system was accompanied by systematic evaluations of prerequisites and consequences. In this paper, we present preliminary results of this evaluation, focusing on prerequisites of computer-based nursing process documentation. We will discuss in detail the creation and use of predefined nursing care plans as one important prerequisite for computer-based nursing documentation. We will also focus on acceptance issues and on organizational and technical issues.

Dependency scoring in a critical care area: a direct nursing assessment method.

The evaluation of dependency in a critical care area can be a difficult process. Often, dependency scoring systems involve time-consuming data completion and collection. The innovative method of dependency scoring described here uses bedside nurses' own assessment of patient needs to provide an accurate and usable scoring system based upon nursing process documentation. It may also provide a method by which dependency may be calculated using computerized systems.

Evaluation of nursing process documentation

Following the introduction of a nursing process and associated documentation in one hospital, an attempt was made to evaluate the effectiveness of the documentation as a record of the nursing process. Two questionnaires were developed, based on previous research in this field, one for the assessment of the documentation, and the other to assess the attitudes and practices of the ward sisters regarding its implementation. The findings indicated that, generally, the assessment phase of the process was poorly documented and that many psychological and social problems were not addressed as well as others. The interventions were relevant but contained little detail. The evaluation section was fair but updating and re-assessment where relevant were poor. Some sisters seemed to display a lack of understanding of the principles or the practice of the process, despite in-service education. Lessons to be learnt from the exercise are suggested.

Measuring nursing outcomes in a psychiatric setting.

Recent developments in health care reform suggest the importance of outcome data regarding the nature, costs, and documented effectiveness of various health care services. While psychiatric nurses believe in the value of the care they provide, the present climate requires that research be conducted to elaborate the outcomes of psychiatric nursing care. This article describes a pilot study conducted on two adult inpatient units of a teaching hospital. On the experimental unit, nurses used North American Nursing Diagnosis Association (NANDA) nursing process documentation that related to specific patient outcome criteria. On the control unit, nurses used a medical systems approach to documentation. Study results and important unanticipated findings are reported with implications for future nursing research and practice.