Quality Of Nursing Documentation Research Articles

The Relationship between Intensive Care Unit’s Nurses’ Informatics Competency and Quality of Patients’ Electronic Health Record’s Documentation

Background: Nursing informatics and the development and growth of health information technology are becoming a necessary part of all aspects of the nursing practice, especially in critical care settings. In addition, researchers agree on using standardized and electronic documentation to support the nursing process and promote nursing documentation quality. Purpose: To examine the relationship between Intensive Care Unit Nurses' Informatics Competency and Quality of Patients' Electronic Health Record Documentation. Methods: A descriptive, correlational, retrospective, cross-sectional design was used. Three hospitals that implemented the Electronic Health Records (EHRs) system were included in this study, using non-probability convenience sampling technique to recruit a total of 176 nurses. The nursing informatics competency was measured by the Self-assessment of Nursing Informatics Competencies Scale (SANICS). The Quality of Electronic Health Record Documentation was assessed by the audit instrument for nursing care plans in the patient record (Cat-ch-Ing). Descriptive and inferential statistics were utilized to answer research questions. Results: The overall mean informatics competency score among nurses was 2.49 (SD = 0.73), with most of the nurses (81.79%) reporting a low competency score of less than three. The highest percentage of participants 29.4% (n = 52) have moderate quality of EHR documentation. Also, related personal and clinical characteristics account for 93.7% of the variance in quality of patients’ electronic health record documentation (R2 = 0.937, F = 8.707, p = 0.004). Once nursing informatics competency was entered into the model, R2 is still the same, making a total explained variance of 93.7% (R2 = 0.937, F = 6.907, p = 0.013). Conclusion: The present study revealed low levels of nursing informatics competency among nurses, and the highest percentage of participants have moderate quality of EHR documentation. In addition, personal and clinical related characteristics account for 93.7% of the variance in the quality of patients’ electronic health record documentation. Implications for Nursing: This study provides evidence to guide nursing leaders, supervisors and policymakers in their planned actions and policies to support nursing capacity, nursing education, and nursing practice in the area of nursing informatics and electronic nursing documentation.

Utilisation and Challenges of Standardised Nursing Languages in Nursing Process Booklets in Selected Tertiary Health Institutions in Nigeria

IntroductionOver the years, hospitals in Nigeria have employed nursing process booklets, but few have adopted the usage of standard nursing terminology, which may have been a better option to document the level of care provided to patients. Currently, there is no published empirical evidence on the utilisation and challenges of standardised nursing languages in nursing process booklets in Nigeria.The purpose of this study was to investigate the use of standard nursing languages and their difficulties in a few Nigerian tertiary healthcare institutions. MethodsIn this study, a descriptive cross-sectional and retrospective design was employed. The medical, surgical, and psychiatric wards of three tertiary healthcare facilities were the three wards that were specifically chosen.Using a simple random sampling method, 427 Nurses and Nursing Process Booklets were chosen. With the threshold of significance set at p < 0.05, SPSS version 25.0 was used for both data administration and analysis. ResultsThe chosen hospitals had moderate rates of use; 49.1%, 50.8%, and 46.7%. Within the study year (2015–2019), there were variations in documentation quality between the hospitals.The quality of nursing process booklets was viewed positively by the respondents. The difficulties faced by nurses were a lack of motivation, inadequate staffing, and a lack of Standardised Nursing Languages (SNL) understanding. The test of association showed that the specialty area had the highest predictive value (B = 0.790). Nursing documentation quality varied significantly between the three hospitals that were chosen, with mean values of (1.3 ± 0.5; 1.6 ± 0.4; 1.5 ± 0.4) respectively. Conclusion and recommendationThe utilisation level was moderate, and fluctuation in documentation by nurses across the selected years was seen in the hospitals. To enhance the quality of nursing documentation in the nursing process booklets, nurses should be taught in standardised nursing languages.

Assessment of Nurses Knowledge Related to Nursing Documentation at Pediatric Surgical Wards

Objectives: The aim of this study is to assess nurse's knowledge about nursing documentation at pediatric surgical wards. Methodology: Using pre- and post-tests for one set of pediatric surgery ward nurses in Baghdad, this study is the core component of a larger study that used a descriptive study design to fulfill the study objectives. Between December 23, 2021, and July 20, 2022, researchers conducted the study. There were three tests: baseline, post-test 1, and post-test 2 in the study group. Results: During pre-test time they show poor levels among all items of the scale. During the post-test 1 and 2, the nurses show good level of knowledge about concept of nursing documentation (Total mean score = 0.86 and 0.77) in which the mean scores show good level among all items of this domain. Conclusion: Nurses has poor knowledge regarding nursing documentation at pediatric surgical wards. There is an association between nurses' knowledge and their (gender, level of education, years of experience and main source of information. Recommendations: Further research is imperative, that will pay more attention to the accuracy of nursing documentation, factors leading to variation in practice, flaws in nursing documentation quality and the effects of these on nursing practice and pediatric patient outcomes.

Effectiveness of an Instructional Program for Nurses' About Nursing Documentation at Pediatric Surgical Wards

Objectives: Evaluate the effectiveness of the instructional program for nurse's knowledge's about nursing documentation at pediatric surgical wards. Study design: A quasi-experimental design was implemented in the research to achieve the study goals by using pre- and post-tests for one group of nurses in pediatric surgical wards. in Baghdad city. The study has been carried out during the period extended from the 23th december 2021 to 20th July 2022. Data collection: It was done at three times: baseline data (before any instruction was provided to the study group), then post-test 1 after 21 days of starting to give the instructional program (in the study group), and post-test 2 after 2 months of starting to give the instructional program. Conclusion: Illustrated from this study, the nurses have poor knowledge regarding nursing documentation at pediatric surgical wards at pretest in study group. Association between nurses' knowledge and their (gender, level of education, years of experience and main source of information. Recommendations: Recommendations were made based on findings. for further research is imperative, that will pay more attention to the accuracy of nursing documentation, factors leading to variation in practice, flaws in nursing documentation quality and the effects of these on nursing practice and pediatric patient outcomes. Keywords: nurses, nursing documentation, pediatric surgical wards.

Standardization of Quality of Diagnoses, Interventions, and Outcomes (Q-DIO) Measurement Instrument for Use in Slovenia.

PurposeTo describe the cross-cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes (Q-DIO) Instrument into the Slovene language.MethodsBased on general international guidelines, a six-step process of localization to translate and adjust the instrument from English into the Slovene language was used. Content validity was quantified based on an agreement of eight experts. The instrument was tested using a sample of 140 nursing documentations from two Slovenian tertiary hospitals.Results26 of 29 items showed an excellent content validity index ranging from 0.857 to 1.000, and a modified kappa index above 0.856. The content validity indexes of the three remaining items adjusted based on experts’ comments were subsequently estimated at 1.000. Construct validity was significantly different between the two groups of documentations. The Cronbach coefficient for the whole questionnaire was 0.860. Cronbach’s alpha if item deleted reamins above 0.80 for all items. The criteria for the difficulty grades of items and discrimination validity were acceptably met for more than 75% of items.ConclusionBased on the results of the study, it may be concluded that Q-DIO is a reliable instrument for measuring the quality of nursing documentation. The deviations in the results of some items are due to poor nursing documentation quality, and indicate that nursing classifications have not yet been fully implemented into practice in the study setting. Additional testing of the instrument is recommended.

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.

Quality of Electronic Nursing Records

Hospital accreditation is a strategy for the pursuit of quality of care and safety for patients and professionals. Targeted educational interventions could help support this process. This study aimed to evaluate the quality of electronic nursing records during the hospital accreditation process. A retrospective study comparing 112 nursing records during the hospital accreditation process was conducted. Educational interventions were implemented, and records were evaluated preintervention and postintervention. Mann-Whitney and χ tests were used for data analysis. Results showed that there was a significant improvement in the nursing documentation quality postintervention. When comparing records preintervention and postintervention, results showed a statistically significant difference (P < .001) between the two periods. The comparison between items showed that most scores were significant. Findings indicated that educational interventions performed by nurses led to a positive change that improved nursing documentation and, consequently, better care practices.

Society for Quality – Croatian Nurses Association, Nursing Documentation Quality

Society for Quality – Croatian Nurses Association, Nursing Documentation Quality

Društvo za kvalitetu - Hrvatska udruga medicinskih sestara, Kontrola kvalitete

Društvo za kvalitetu - Hrvatska udruga medicinskih sestara, Kontrola kvalitete

Assessment of quality in psychiatric nursing documentation - a clinical audit.

BackgroundQuality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital.MethodA cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points).ResultsThe item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items.ConclusionsDeficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.

Application of continuous quality improvement in the quality control of nursing documentation

Objective To explore the application effect of continuous quality improvement in the quality control of nursing documentation , and carry out the whole monitoring of the quality of writing nursing documentation so as to improve the quality of nursing documentation .Methods The groups of quality control of nursing documentation in the departments and the department of nursing were established in order to the effective supervision and guidance of writing nursing documentation in the whole process .One thousand two hundred and fifty-one archived medical records from August 2013 to December 2013 were chosen as the observation group , and 1162 records from September 2012 to January 2013 were chosen as the control group .The incidence of defects was compared between two groups .Results The incidences of defects including the temperature records, doctor’s advice, the admission and discharge evaluation records and nursing records were respectively 4.40%,2.80%,4.16%,13.11%in the observation group, and were 11.53%,9.03%,15.49%,35.80% in the control group, and the differences were statistically significant （χ2 =42.487,42.898,84.873,160.424, respectively;P〈0.01）.Temperature records, doctor’s advice, the admission and discharge evaluation records in each defect rate in the observation group were lower than the control group , the difference was statistically significant （P〈0.01）.Incidence rate of most of the problems in nursing records in observation group were lower than the control group , the incidence of individual problems between the two groups has no statistical significance （ P 〉0.05 ）.Conclusions The groups of quality control of nursing documentation in the departments and the department of nursing play important role in the whole process management of writing nursing documentation so as to improve the quality of nursing documentation . Key words: Nursing management Nursing documentation Continuous quality improvement

Quality improvement in clinical documentation: does clinical governance work?

IntroductionThe quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation.MethodsA quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist.ResultsThere were no differences between a nurse’s demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program.ConclusionAlthough some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.

Evaluation of a Mobile Shift Report System on Nursing Documentation Quality

Nursing shift report is vital for patient care. Accordingly, healthcare facilities have made great efforts to establish a standardized nurse-to-nurse shift handoff process to ensure patient care quality. The purpose of this study was to determine whether the use of a standardized mobile intershift handoff system would affect the quality of nursing documentation. The study is based on nursing handoff records from 19 inpatient units in four major care areas (internal medicine, general surgery, obstetrics/pediatrics, and long-term care) of a medical center in central Taiwan. Data collection was performed before and after implementation of the mobile, point-of-care handoff system in 2010. A medical review tool was used to compare 25-item charting compliance on 228 charts. Results show that the designed content of the handoff system was related to a corresponding compliance change in initial assessment, pain reassessment, and use of accurate abbreviation. Although overall compliance rates among inpatient units varied, the statistical test showed that the pattern of changes was consistent. As more items were added to the new handoff system for reminder purposes, documentation compliance increased; however, since the new handoff system did not include nursing diagnosis, patient outcome tracking compliance was reduced. The results of the study reveal that implementing a standardized point-of-care handoff system could improve nursing documentation compliance and quality.

Einsatz von Klassifikationen in der Pflege

To ensure better-quality documentation of patients’ nursing care needs and prepare for DRGbased funding, many hospitals have started implementing the NANDA-I classification for nursing diagnoses. The Burgerspital Solothurn (soH AG) started this implementation process in 2001, followed by development of an electronic nursing documentation system containing internationally recognised terminologies and a standardised infrastructure for data management. Not only have evaluations shown enhanced quality of nursing documentation; studies have also revealed that the implementation of NANDA-I diagnoses enhances assessment of nursing care needs. Moreover, implementation of standardised nursing diagnoses leads to more effective nursing interventions and significantly better patient outcomes. This article describes a nursing documentation system that is now commercially available.

Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study

To evaluate the impact of the quality of nursing diagnoses, interventions, and outcomes in an acute care hospital following the implementation of an educational program. In a pretest-posttest experimental design study, nurses from 12 wards of a Swiss hospital received an educational intervention--an introductory class and consecutive classes, using a case discussion method--to implement nursing diagnoses, interventions, and outcomes. Two sets of 36 randomly selected nursing records were evaluated before and after implementation. The quality of documented nursing diagnoses, interventions, and nursing-sensitive patient outcomes was assessed by 29 Likert-type items with a 0-4 scale instrument, called Quality of Nursing Diagnoses, Interventions, and Outcomes (Q-DIO) and tested using t-tests. Significant enhancements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of a planned educational program. The implementation of NANDA, NIC, and NOC (NNN) nursing diagnoses, interventions, and outcomes led to higher quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursing-sensitive patient outcomes. Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.