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Ehrenberg, Anna. "In pursuit of the common thread : Nursing content in patient records with special reference to nursing home care." Doctoral thesis, Uppsala University, Department of Public Health and Caring Sciences, 2000. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-495.
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The purpose of this thesis was to study different aspects of nursing content in patient records with special reference to nursing home care. The thesis focused on the content, comprehensiveness, accuracy and auditing of records, as well as the practice and perceptions of nurses in relation to recording. A national sample of nurses was asked to complete a questionnaire. The effects on recording and nurses' practice and perceptions in nursing homes following educational intervention were studied. Accuracy was examined through record reviews and interviews with nurses and patients. A literature review of record auditing methods was performed and findings from this search were applied in the assessment of a set of records.
The results indicate that the VIPS model, as a structure for nursing recording, is widespread and shows validity across various areas in Swedish health care. After the educational intervention program, documentation in nursing home care improved significantly in the study group concerning notes on nursing history, nursing status, nursing diagnoses, interventions and discharge notes. Systematic and comprehensive assessment grounded in research-based criteria were not used in the records. Accuracy varied considerably and was significantly better for some areas in the study group. After intervention, the nurses in the study group indicated that they recorded assessments of patients with greater frequency, showed greater satisfaction with their documentation and spent less time on oral reports. Procedures in auditing patient records were found to encompass four approaches: formal structure, process comprehensiveness, knowledge based and accuracy.
In conclusion, the evidence suggests that there are serious flaws in the nursing content of nursing home records though improvements can be achieved through educational means. Presently, there are serious limitations in using the patient record as the sole source of data for care delivery, quality assessment and evaluation of care.
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Törnvall, Eva. "Carrying out electronic nursing documentation : use and development in primary health care /." Linköping : Department of Social and Welfare Studies, Linköping University, 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-11268.
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Alexander, Gregory Lynn. "Human factors, automation, and alerting mechanisms in nursing home electronic health records." Diss., Columbia, Mo. : University of Missouri-Columbia, 2005. http://hdl.handle.net/10355/4128.
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Thesis (Ph. D.)--University of Missouri-Columbia, 2005.The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Vita. "July 2005." Includes bibliographical references.
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Ferencsik, Leesuk Sim. "The lived experience of nurses transitioning to electronic medical records usage| A phenomenological inquiry." Thesis, Barry University, 2017. http://pqdtopen.proquest.com/#viewpdf?dispub=10261435.
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Background: One of the most pressing global issues in health care settings is patients’ safety. In an effort to decrease medical errors and improve the quality of patient care, many health care organizations have adopted an electronic medical record (EMR) system. The federal government supported this widespread EMR implementation with multi-billion dollar financial support. However, to date, the lived experience of the nurses transitioning to EMR is not clearly understood. Purpose: The purpose of this study was to explore the lived experience of nurses transitioning to EMR usage.
Philosophical Underpinnings: This qualitative study followed van Manen’s phenomenological perspectives under the naturalistic (constructivist) paradigm with the research question, “What is the experience of nurses transitioning to electronic medical records (EMRs) usage?”
Methods: A qualitative phenomenological methodology was used for this study. A purposive sample of 15 nurses who have experienced transitioning to the EMR usage was selected to explore the lived experience of nurses transitioning to electronic medical records (EMR) usage with the overarching question: What is the lived experience of nurses transitioning to EMR usage like? Data collection occurred with in-depth, semi-structured interviews using open-ended questions. Each individual interview was tape-recorded, transcribed verbatim, and member checked. Data analysis was guided by Max van Manen’s (1990) phenomenological method, which includes describing, interpreting, textual writing and rewriting. Data analysis resulted in a rich and thoughtful representation and increased understanding of what it is like for nurses transitioning to EMR usage.
Results: Four core themes Doubting, Struggling, Accomplishing, and Embracing emerged. Three subthemes emerged: Balancing time between computer and patients and Increasing workloads and responsibility, which are subthemes of Struggling, and Leaving human interaction behind, a subtheme of Accomplishing. These themes illuminated the lived experience of 15 nurses transitioning to EMR usage. Thomas Kuhn’s (1996) process of scientific inquiry provided a framework to gain a deeper understanding of this phenomenon.
Conclusions: This study explored the lived experience of nurses transitioning to EMR usage in hospital settings. The results of the inquiry highlighted the essence of participants’ experience by revealing their doubt about the EMR’s functionality, struggle with transitioning and using the new EMR system, accomplishment of successful transition to the EMR system, and finally acceptance of technology in their daily work practice. The findings of this study contributes to the debate about EMR usage in nursing practice to engage nurses to ponder how they provide quality, patient-centered care while using the EMR system to reach the common goal of provision of quality care.
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Aruldass, Ruby. "Structured Education Using Scenario-Based Training in Cerner Electronic Medical Records." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/6515.
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Nurse practitioners are trained to use the electronic medical record (EMR) to document. Documentation in the EMR is often found to be incomplete, inaccurate, and unreliable, which affects the quality of care and patient safety outcomes. The purpose of the project was to improve the efficiency and effectiveness of nurse practitioners' documentation in the EMR. Malcolm Knowles' adult learning theory was used in this project to develop the education program. Kirkpatrick's training evaluation model was also used to analyze and evaluate the project. The study population included 5 primary care nurse practitioners in an ambulatory care setting using Cerner EMR. The practice-focused question was centered on whether a structured scenario-based training in Cerner would improve the completeness, accuracy, and reliability of EMR documentation. The 5 nurse practitioners were educated using structured, scenario-based training in EMR. The Cerner Advance database showed that there was an average decrease of two seconds in the documentation post-education when compared to the documentation time pre-education. Results for patient quality outcomes indicated that 2 out of 3 quality measures were performed above the national mean. The implication of this study for positive social change includes providing structured education using scenario-based training to help nurse practitioners provide quality care and promote better patient outcomes.
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Steiner, Bridget Anne. "Electronic medical record implementation in nursing practice a literature review of the factors of success /." Thesis, Montana State University, 2009. http://etd.lib.montana.edu/etd/2009/steiner/SteinerB0509.pdf.
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This is a review of the current literature to discern what factors need to be present in an electronic medical record (EMR) implementation in order for it to be successful for nurses. An extensive literature search was performed by using databases CINAHL, MEDLINE, and Health Reference Center for primary sources of research that specifically addressed EMR implementation and nursing. A coding scheme was developed and applied to each article for analysis. It was found that fit of the EMR with nurse functions, education, and positive nurse attitude were the three most common factors associated with successful EMR implementation for nurses. Lack of computer system quality, lack of fit of the EMR with nurse functions, and time requirements of its use were most commonly associated with lack of success.
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Latha, Sampath Shakti. "Comprehensive Understanding of Injuries in Hospitals through Nursing Staff Interviews and Hospital Injury Records." University of Cincinnati / OhioLINK, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1544101088645945.
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Munkvold, Glenn. "Making IT Work in Practice Integrating the EPR-based nursing record with nursing work." Doctoral thesis, Norwegian University of Science and Technology, Department of Computer and Information Science, 2007. http://urn.kb.se/resolve?urn=urn:nbn:no:ntnu:diva-1933.
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The Norwegian healthcare sector, like the rest of the Western world, faces major challenges related to the need to coordinate work within and across institutional anddisciplinary boundaries. The main materialization of the ongoing efforts of streamlining healthcare services is the formalization of healthcare work through the Electronic-Based Record (EPR). In this thesis I explore one particular aspect of these efforts: nursing care and the formalization of nurse’s written accounts in the EPR-based nursing record.
Nurses play an essential role in ensuring that there is a well-functioning organization and a seamless management of patient trajectories. With increased emphasis on integrated care as the standard model for delivering healthcare services, the contribution of the nursing profession to the overall delivery of care is increasingly acknowledged.
This thesis explores how nursing is documented in practice and how the EPR-based nursing module is integrated in specific nursing work practices. Empirically the thesis is based on ethnographically inspired fieldwork at the Department of Rheumatology at St. Olavs University Hospital in Trondheim and the Department of Special Psychiatry at the University Hospital in Tromsø. In both cases I have studied nurse’s documentation practice and the integration of the EPR-based nursing record into their everyday work.
The thesis has a strong focus on how things are done in practice. The set of papers presented as part of this thesis make some of the work involved in formalizing nurse’s written accounts visible and also present the EPR-based nursing record in practice. The main contribution of the thesis is a detailed, empirically underpinned exploration of the efforts of introducing the electronic-based nursing module in practice. I apply a process-oriented perspective on the nursing record that stresses how it is situated, its temporal nature, how it is regularly (re)negotiated and achieved in practice.
Integrating the EPR-based nursing record with the aim of improving information sharing is extremely difficult. In the Trondheim case it is demonstrated how efforts of formalizing nurse’s work through the EPR introduced new types of informal elements. In fact, the informal, redundant and unstructured aspects of nurse’s work that initially were considered to be a problem became essential for the new formalized practice to work. Similarly in Tromsø, the standardization of nursing plans unintentionally subverted the possibilities for interdisciplinary cooperation. Rather, it was the existing and heterogeneous (informal/formal and oral/written) documentation and communication practice that contributed to interdisciplinary work and made up and served as a premise for a good nursing plan.
The thesis contributes to theory by presenting a dynamic perspective on the nursing record as resilient, open and achieved in practice. The thesis contributes to the literature within Computer Supported Cooperative Work (CSCW) on informal documentation practices and expressions of redundancy by demonstrating how these are transformed when new technologies are being implemented. Also the thesis contributes to the existing CSCW literature by demonstrating the necessity of accommodating temporal differences that arise from separate and different intragroup processes.
The aims and goals related to the EPR change and expand over time and in relation to multiple stakeholders. For example, in the Tromsø case the nursing plan, which started out as tool for nurses, gradually turned into a resource management tool. Such transformations of ambitions are typical in information system projects and should not come as a surprise - primary work transforms things into something different where technologies find new areas of application.
In order to succeed in integrating tools such as the EPR-based nursing record with work, one needs to move beyond simplistic strategies of replacing the existing information sources. The strategy to pursue is to find mechanisms that strengthen the relations between the parts. For practice this implies balancing rational aims and practical applicability when designing and implementing new tools. Also, it involves paying closer attention to what is non-common, for example what types of information sometimes remains specific for the various professionals, and why.
Methodologically, the interconnected and mutually dependent entities of material arrangements and practices of different professionals underscore the need for doing empirical studies in a work setting by following the whole process of implementing a new system (before, during and after). Also, in order to make research findings practically relevant, researchers should engage themselves in arenas that enable learning to take place, where knowledge can be shared and where local competence and capacity are cultivated. Rather than presenting a fixed set of requirements as implications for design, we should struggle to build relationships between politically contrasting interests, for example between vendors, managers and the users. Design implications are in this sense not fixed once and for all, but instead serve as a starting point for discussion, reflection and negotiated changes with various stakeholders.
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Dunn, Kristina Ann. "Nursing Informatics Competency Program." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/3985.
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Currently, C Hospital lacks a standardized nursing informatics competency program to validate nurses' skills and knowledge in using electronic medical records (EMRs). At the study locale, the organization is about to embark on the implementation of a new, more comprehensive EMR system. All departments will be required to use the new EMR, unlike the current policy that allows some areas to still document on paper. The Institute of Medicine, National League of Nursing, and American Association of Colleges of Nursing support and recommend that information technology be an essential core competency for nurses. Evidence of the need for nursing informatic competencies was found through a literature search using CINHAL, Proquest Nursing, Medline, and Pubmed search lines. Concepts searched were competencies, nursing informatics, health information technology, electronic health record, information technology literacy, nursing education, information technology training, and curriculum. The Staggers Nursing Computer Experience Questionnaire was distributed to 300 nurses practicing within the hospital setting to obtain baseline data on current nursing computer knowledge and skill level. This validated tool was created by Nancy Staggers in 1994 and used in other process improvement efforts similar to this one. The assumption was that nursing competency levels with computers were varied through the hospital. The data obtained from the questionnaire, through Zoho Survey tool, confirmed this assumption and were used to help create the education, support, and competency plan for the future. Data was analyzed through the built-in reports and interactive charts that the Zoho survey tool provides. The new EMR and all the new processes that come with it will be the framework of nursing care. Having competent nurses in the use of the EMR will optimize the quality of patient care delivered.
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Yeung, Kit-ting. "Spiritual care in nursing practice /." View the Table of Contents & Abstract, 2007. http://sunzi.lib.hku.hk/hkuto/record/B38295775.
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Tseng, Hui-Chen. "Use of standardized nursing terminologies in electronic health records for oncology care: the impact of NANDA-I, NOC, and NIC." Diss., University of Iowa, 2012. https://ir.uiowa.edu/etd/1409.
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The purpose of this study was to identify the characteristics of cancer patients and the most frequently chosen nursing diagnoses, outcomes and interventions chosen for care plans from a large Midwestern acute care hospital. In addition the patients' outcome change scores and length of stay from the four oncology specialty units are investigated. Donabedian's structure-process-outcome model is the framework for this study. This is a descriptive retrospective study. The sample included a total of 2,237 patients admitted on four oncology units from June 1 to December 31, 2010. Data were retrieved from medical records, the nursing documentation system, and the tumor registry center. Demographics showed that 63% of the inpatients were female, 89% were white, 53 % were married and 26% were retired. Most patients returned home (82%); and 2% died in the hospital. Descriptive analysis identified that the most common nursing diagnoses for oncology inpatients were Acute Pain (78%), Risk for Infection (31%), and Nausea (26%). Each cancer patient had approximately 3.1 nursing diagnoses (SD=2.5), 6.3 nursing interventions (SD=5.1), and 3.7 nursing outcomes (SD=2.9). Characteristics of the patients were not found to be related to LOS (M=3.7) or outcome change scores for Pain Level among the patients with Acute Pain. Specifically, 88% of patients retained or improved outcome change scores.
The most common linkage of NANDA-I, NOC, and NIC (NNN), a set of standardized nursing terminologies used in the study that represents nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions, prospectively, was Acute Pain--Pain Level--Pain Management. Pain was the dominant concept in the nursing care provided to oncology patients. Risk for Infection was the most frequent nursing diagnosis in the Adult Leukemia and Bone Transplant Unit. Patients with both Acute Pain and Risk for Infection may differ among units; while the traditional study strategies rarely demonstrate this finding. Identifying the pattern of core diagnoses, interventions, and outcomes for oncology nurses can direct nursing care in clinical practice and provide direction for future research tot targets areas of high impact and guide education and evaluation of nurse competencies.
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Rodgers, Catherine. "Diminishing Incontinence in Long-Term Care using Electronic Health Records." ScholarWorks, 2014. https://scholarworks.waldenu.edu/dissertations/34.
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Urinary incontinence affects up to 70% of residents living in a long-term care facility and can affect their quality of life. Specifically, urinary incontinence has a direct impact on older adults in regards to self-esteem, pressure ulcer development, falls, urinary tract infections, and psychosocial wellbeing. The goal of this quality improvement pilot project was to determine if an electronic health record (EHR) assessment tool could help older adults remain continent longer and assist in maintaining an independent lifestyle. Orem's self-care deficit theory and social cognitive theory were used to determine how the electronic health record incontinence template could be used to monitor residents for incontinence and affect the incidence of incontinence. Out of 25 residents, 13 met the requirements for inclusion in the pilot study. Quantitative data were collected and documented in the EHR for 4 weeks and compared to the immediate 4 week period post-implementation of the EHR template. Descriptive analyses of pre- and post-implementation EHR assessments showed there were no EHR assessments completed pre-implementation and 2 residents out of 13 had EHR assessments completed post-implementation. The available data suggested that the EHR template, if edited, could be effective for tracking incontinence. The template needed to address bladder incontinence only rather than bowel and bladder. Feedback from nursing staff indicated that a future study should be conducted over a longer period than 4 weeks to see if results would remain consistent. Nurses working in the long term care environment would benefit from reading this project. This study contributes to social change as evidenced by the residents who remained continent longer by having individual toileting plans partially developed by the template; therefore, they remained a viable part of the community.
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Oliveira, Neila Regina de. "Experiencia de implantação e operacionalização do processo de enfermagem em um Hospital Universitario." [s.n.], 2008. http://repositorio.unicamp.br/jspui/handle/REPOSIP/310952.
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Orientador: Maria Helena Baena de Moraes LopesDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: O Centro de Atenção Integral à Saúde da Mulher (CAISM) da Universidade Estadual de Campinas (UNICAMP), desde o início de suas atividades, em 1986, vem buscando incorporar à prática assistencial o Processo de Enfermagem (PE). Porém, sua operacionalização sofreu muitas interferências que a tornaram lenta e difícil. O presente estudo teve como objetivo descrever a operacionalização do PE no CAISM/UNICAMP, desde sua implantação, até o momento atual, buscando identificar quais foram os eventos relevantes relacionados a mesma e resgatar junto às pessoas envolvidas, as dificuldades, as estratégias utilizadas e mudanças ocorridas a partir do processo vivenciado pelas pessoas envolvidas. Trata-se de estudo descritivo e exploratório. Foram realizadas entrevistas pessoais ou por meio da internet e também um questionário quando não foi possível o contato pessoal. Por meio de instrumento específico foi realizada análise documental. A amostra foi estabelecida por conveniência, utilizando-se o método da "bola-de-neve". Foram analisados 82 documentos, identificados 53 eventos relevantes e 27 enfermeiros foram entrevistados ou responderam ao questionário. Dentre os eventos relevantes, destacam-se a Integração Docente-Assistencial e o Programa de Educação Continuada, a evasão de enfermeiros, a extinção temporária do Programa de Educação Continuada e a alteração da jornada de trabalho dos enfermeiros contribuíram negativamente. A principal dificuldade inicial, na implantação do PE, foi a descrença, pelos próprios enfermeiros, no Processo (22,2%). Das dificuldades ocorridas desde a implantação, e que permanecem até o momento atual, a resistência, o desinteresse, a falta de envolvimento dos enfermeiros foram as principais. A falta de planejamento e de estabelecimento de prioridades relacionadas à assistência constituem as maiores dificuldades que surgiram no momento atual. A estratégia utilizada nessa operacionalização, considerada pelos entrevistados como mais adequada, foi o estudo de caso, que perde o seu valor quando ocorre falta de continuidade. A principal mudança ocorrida, percebida por eles, foi a adoção de partes ou totalidade do PE na assistência, com sua conseqüente melhoria. Concluiu-se que as dificuldades ainda existem e uma estratégia para vencê-la seria a retomada e manutenção dos estudos de casos. Para isso, sugere-se, ainda, que os processos de trabalho também sejam revistos e discutidos com a equipe de enfermagem
Abstract: The Center of Integral Attention of the Women Health (CAISM) from Campinas University (UNICAMP), is trying to incorporate to the regular assistance the process of nursing (PN) since the beginning of the activities in 1986, but this process suffered many interferences that had become it slow and difficult. This paper had the objective to describe how the introduction of the process of nursing in the CAISM/UNICAMP was made from the first days until the current moment, identifying all the important events in implantation; talking to the people involved, asking them about the difficulties the strategies and the changes through this time . This is a descriptive and exploratory study. Personal interviews and interviews by internet were made and a questionnaire was used when the personal contact was impossible. The documental analysis was made by a specific instrument. The sample was choosing by convenience, using the method of the snow ball. Eight two documents had been analyzed, fifty three important events were identified and twenty seven nurses were interviewed or answer the questionnaire. Among all the important events the integration professor- assistance and the program of Continue Education had prominence. Some events had a negative influence like the temporary extinguishing of the program of continued education, and the change of the shifts of nurses. Many nurses even abandon the institution because of this .The main difficult in the process of implantation of the PN was the incredulity of the own nurses with 22.2%. Among all the difficulties since the beginning until now, some still persist like: resistance, the disinterest and the lack of involvement of the nurses are the main ones. The lack of planning and establishments of priorities related to the assistance were the biggest difficulties that had appeared at the current moment. The most adequate strategy used in this work according to the interview was the study of the case that loses his value when the work is interrupt. The main change showed in the interview was the adoption of the PN and the improvement because of that. The conclusion is: there is a lot of problems to bypass and a strategy to do this is retake the study of the cases. For this one suggest the review of some working process and a discussion with the nursing team
Mestrado
Enfermagem e Trabalho
Mestre em Enfermagem
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Gephart, Sheila M., Alycia A. Bristol, Judy L. Dye, Brooke A. Finley, and Jane M. Carrington. "Validity and Reliability of a New Measure of Nursing Experience With Unintended Consequences of Electronic Health Records." LIPPINCOTT WILLIAMS & WILKINS, 2016. http://hdl.handle.net/10150/621591.
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Unintended consequences of electronic health records represent undesired effects on individuals or systems, which may contradict initial goals and impact patient care. The purpose of this study was to determine the extent to which a new quantitative measure called the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire (CG-UCE-Q) was valid and reliable. Then, it was used to describe acute care nurses' experience with unintended consequences of electronic health records and relate them to the professional practice environment. Acceptable content validity was achieved for two rounds of surveys with nursing informatics experts (n = 5). Then, acute care nurses (n = 144) were recruited locally and nationally to complete the survey and describe the frequency with which they encounter unintended consequences in daily work. Principal component analysis with oblique rotation was applied to evaluate construct validity. Correlational analysis with measures of the professional practice environment and workarounds was used to evaluate convergent validity. Test-retest reliability was measured in the local sample (N = 68). Explanation for 63% of the variance across six subscales (patient safety, system design, workload issues, workarounds, technology barriers, and sociotechnical impact) supported construct validity. Relationships were significant between subscales for electronic health record-related threats to patient safety and low autonomy/leadership (P < .01), poor communication about patients (P < .01), and low control over practice (P < .01). The most frequent sources of unintended consequences were increased workload, interruptions that shifted tasks from the computer, altered workflow, and the need to duplicate data entry. Convergent validity of the CG-UCE-Q was moderately supported with both the context and processes of workarounds with strong relationships identified for when nurses perceived a block and altered process to work around it to subscales in the CG-UCE-Q for electronic health record system design (P < .01) and technological barriers (P < .01).
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Ntsoele, Motsegoane Monica Naomi. "An evaluation of the effective use of computer-based nursing information system in patient care by professional nurses at Dr George Mukhari Hospital." Thesis, University of Limpopo ( Medunsa Campus), 2011. http://hdl.handle.net/10386/408.
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Thesis (M Cur)--University of Limpopo, 2011.An evaluation of the effective use of Computer-based Nursing Information System (CNIS) in patient care by Professional nurses at Dr George Mukhari Hospital. The aim of the study was to evaluate if the CNIS is being used effectively for patient care by professional nurses in different nursing units. The objectives of the study were to describe the perceptions of professional nurses regarding the role of CNIS, to determine the effective use of CNIS, and to identify barriers to the effective use of CNIS in patient care. Quantitative descriptive simple survey research design was used. The setting was at Dr George Mukhari Hospital. The population was all professional nurses who are working on day and night shifts in the wards that have computers installed for the purpose of patient care. Non probability, convenience sample of 120 professional nurses was used. Data was collected utilising a self report questionnaire with 41 closed ended and one open ended questions. Raw data was fed into a SPSS with the assistance of a statistician. Data analysis was conducted through the use of descriptive statistics. The findings are that professional nurses are not using CNIS effectively in patient care. In a unit with a bed occupancy rate of 30-40 patients, and where 30-40 patients are attended to on a daily basis, only 0-2 Nursing Care Plans (NCP) or entries are performed by professional nurses. The majority of professional nurses (56%) never updated NCPs or made an entry before. This is despite the fact that they have indicated positive perceptions with regard to the role of CNIS in patient care. Increased workload, inadequate number of computers, and lack of continuous in-service training were cited by the majority as barriers to the effective use of CNIS in patient care. A problem of increased workload will remain a challenge for as long as available technology is not used appropriately. Hence, hand held devices such as Personal Digital Assistants (PDAs), Electronic Health Records (EHRs) and bedside terminals, are highly recommended. Key concepts: Computer, Nursing, Information, System, Evaluation, Effective, Professional Nurses, Patient care.
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Obua, Uche Gerard. "Strategies for Reducing Medication Errors in an Outpatient Internal Medicine Clinic." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/6638.
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Medication errors are among the most common causes of unintended harm to patients and have led to many deaths. Some categories of medication errors include; medications administered to the wrong person; medications administered at the wrong time, through the wrong route; administration of the wrong medication and/or dose; and the omission of medications. Guided by the logic model, the just culture model, and the Knowles theory of andragogy, the purpose of the project was to determine if providing information related to evidence-based strategies to reduce medication errors would result in safer medication administration practices and improved patient outcomes A survey was administered to 11 medical and nursing staff at an outpatient internal medical clinic to determine their knowledge about medications errors prior to providing evidence-based information on strategies to reduce medication errors. After the educational session, a survey was conducted to determine staff members' retention of knowledge. A significant increase in the percent of correct responses to the survey from 68% to 100% after the educational session (t = -3.9; p = 0.001)) shows that the educational in-service had a positive outcome in increasing staff members' knowledge about reducing medication errors in an out-patient internal medicine clinic. Improving clinic staff knowledge and behaviors regarding medication administration has the potential to bring about social change by decreasing medication errors, improving patient safety, and improving health outcomes.
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Yip, Shuaih-yee Bethia. "Oral care practice in cancer nursing /." View the Table of Contents & Abstract, 2006. http://sunzi.lib.hku.hk/hkuto/record/B36397040.
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Geoghegan, Mary Denise. "A Review of whether peri-operative nursing records used in the Western Cape Metropolitan health region are in line with international standards and recommendations for standard content and design characteristics for the Western Cape." Master's thesis, University of Cape Town, 2000. http://hdl.handle.net/11427/2948.
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Bibliography: leaves 180-193.Peri-operative nursing is faced with increasing pressure to improve productivity while coping with diminishing resources. Nurses have to work harder and faster while still maintaining a high standard of patient care. This emphasises the need for comprehensive, yet easy-to-use peri-operative nursing records. A descriptive, non experimental research design was used to survey peri-operative nursing records used in the Western Cape Metropolitan Health Region and content and design characteristics were identified. A comparison was made between these records and the standard set by the Association of Operating Room Nurses (AORN) in the United States of America. The criteria stipulated by the AORN standard were found to be relevant to South African peri-operative nursing practice with a few exceptions. In spite of this, the perioperative nursing records reviewed did not compare well with the AORN standard and were particularly deficient in risk management areas such as potential injury related to positioning the patient, and electrical and physical hazards. Content criteria not mentioned by the standard, but appearing in the local records were identified and certain aspects of design recognised in the literature were also discussed. Recommendations for a South African standard for peri-operative nursing records were made, as well a$ recommendations for further research into the use and design of peri-operative nursing records.
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Van, Eeden Ilze Emelia. "Development of a nursing record tool for critically ill or injured patients in an accident and emergency (A & E) unit." Diss., Pretoria: [s.n.], 2009. http://upetd.up.ac.za/thesis/available/etd-11252009-233615/.
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Björvell, Catrin. "Nursing documentation in clinical practice : instrument development and evaluation of a comprehensive intervention programme /." Stockholm, 2002. http://diss.kib.ki.se/2002/91-7349-297-3/.
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Giolito, Paula Carvalho Barbosa de Oliveira. "Instrumento para registro dos enfermeiros em uma unidade pediátrica: o uso da metodologia da problematização." Universidade Federal Fluminense, 2015. https://app.uff.br/riuff/handle/1/1720.
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Mestrado Profissional em Enfermagem Assistencial
Introdução: Trata-se de um estudo que possui como objeto o registro dos enfermeiros em um setor de pediatria. Objetivos: Elaborar um roteiro para orientação de registros de enfermeiros em pediatria; aplicar a metodologia da problematização para identificar os cuidados e os aspectos relacionados à elaboração dos registros em pediatria; discutir as implicações desses aspectos para o registro de enfermagem em pediatria tendo em vista as situações-problema vivenciadas pelos enfermeiros. Método: Estudo descritivo, com abordagem qualitativa, realizado num hospital pediátrico do município de Duque de Caxias, com a participação de 12 enfermeiros. As informações foram coletadas através de formulários individuais e da abordagem em grupo sobre o tema registro de enfermagem, utilizando a metodologia da problematização. Tais informações foram analisadas utilizando a Análise de Conteúdo, originando duas categorias: 1. As situações-problema que interferem na prática assistencial dos Enfermeiros e 2. Estratégias para otimização do tempo na realização do registro de Enfermagem em Pediatria. Resultados: Os enfermeiros relacionaram as seguintes situações-problema que podem interferir na realização do registro em conformidade com a SAE: situações de caráter institucional e situações de relacionamento interpessoal. Elegeram como problema prioritário o tempo para executar o processo de enfermagem e fazer um bom registro. Dentre as hipóteses de solução para o problema, o grupo elaborou coletivamente o Instrumento para Registro dos Enfermeiros em Pediatria. Considerações Finais: O uso da Metodologia da Problematização em uma pesquisa qualitativa no cenário pediátrico foi bastante produtivo e enriquecedor, pois possibilitou aprofundar o conhecimento na área da Enfermagem Pediátrica, aliando conhecimentos teóricos adquiridos à prática, partindo da reflexão para a ação resolutiva. A construção do Instrumento de forma coletiva evidenciou o que é preconizado na Problematização: a estimulação da relação prática-teoria-prática, com vistas à transformação da realidade vivida.
Introduction: This is a study that has as object the nurse’s record in a pediatric sector. Objectives: Develop a guide to nurses records in pediatrics; apply the methodology of Problematization to identify nursing care and aspects related to the elaboration of the records in pediatrics; discuss the implications of these aspects for nursing record in pediatrics in view of the problem situations experienced by nurses. Methods: A descriptive study with qualitative approach developed in a pediatric hospital in the city of Duque de Caxias, in which participants were 12 nurses. Data were collected through individual forms and group approach about the subject “nursing records”, using the methodology of Problematization. The data were analyzed using content analysis, through which have been defined two categories: 1. The problem situations that interfere in the practice of nurses and 2. Strategies for optimization of time in making the nursing record in Pediatrics. Results: The nurses related the following problem situations experienced in everyday practice that can interfere in making the record in accordance with SAE: institutional situations and interpersonal situations. They elected as main problem the time to run the nursing process and make a good nursing record. Among the hypotheses for solving the problem, the group collectively elaborated the Instrument for Pediatric Nurses’ Record. Conclusion: The use of the Methodology of Problematization in a qualitative research in pediatric setting was very productive and enriching because it allowed to deepen the knowledge in the area of Pediatric Nursing, combining theoretical knowledge into practice, starting from the reflection to the resolutive action. The construction of the Instrument in a coletive way showed what advocates the Problematization: stimulation of practice-theory-practice relationship, with a view to transforming the lived reality.
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Leonardi, Rosana Claudia de Assunção. ""Avaliação dos aspectos éticos e legais dos registros de enfermagem na parada cardiorrespiratória em hospital escola do Paraná"." Universidade de São Paulo, 2005. http://www.teses.usp.br/teses/disponiveis/22/22132/tde-20062005-101556/.
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A reanimação cardiopulmonar no hospital é um evento complexo, exigindo dos profissionais de saúde conhecimentos científicos, bem como habilidades e competências, tanto no atendimento do evento, como no registro do prontuário. Assim, o objetivo deste estudo foi avaliar os aspectos éticos e legais dos registros de enfermagem no atendimento a pacientes que apresentaram parada cardiorrespiratória e foram a óbito no ano de 2003, em um hospital escola do interior do Paraná. A metodologia utilizada foi um estudo descritivo, retrospectivo, transversal com abordagem quantitativa dos registros de enfermagem, efetuados pela equipe de enfermagem no prontuário do paciente. Após analisarmos 114 prontuários pôde-se observar uma grande lacuna nos registros de enfermagem quanto aos aspectos éticos e legais. Seguindo as orientações de Du Gás (1998) em relação à identificação da categoria funcional, encontramos 101 (88,60%) registros sem identificação; em relação aos dados de identificação do profissional encontramos 108 (94,74%) destes feitos de forma inadequada. Nas medidas terapêuticas, realizadas pelos vários membros da equipe, nos deparamos com 103 (90,35%) registros sem informação Observamos que a respeito das informações pertinentes ao estado geral do paciente tais informações não estão presentes em 108 (94,74%) dos registros e que em 92 (80,7%) deles em relação às respostas específicas do paciente quanto à terapia e à assistência tampouco houveram Com base no referencial teórico de Potter e Perry (2004) referente à concisão e organização 114 (100%) registros apresentaram-se inadequados. Dessa forma verificamos que existe uma deficiência na elaboração dos registros de enfermagem, o que é inconcebível tanto no aspecto legal quanto na ética.The cardiopulmonary resuscitation in the hospital is a very complex event, requiring from its staff scientific knowledge as well as skills when attending on the event and when registering specific data on the medical chart. This study focuses on the evaluation of the ethical and legal aspects of the nursing record regarding the attendance on patients who went through a cardiorespiratory arrest and died within the year 2003 in a teaching hospital in the countryside of Paraná. The methodology used was a descriptive, retrospective, transversal study with a quantitative approach of the nursing record ran by the nursing staff in the patients record. After analyses of 114 records it has been observed a lack of ethical and legal issues in the nursing records. Following the instructions given by Du Gás (1998), we have found 101 (88,60%) without functional category identification, 108 (94,74%) had inadequate staffs data.103 (90,35%) lacked information regarding therapeutic measures taken, 108 (94,74%) did not have relevant observations on the general state of the patient and in 92 (80,7%) we have found no register of the results taken from the patient regarding the therapy and assistance recieved. .According to the theorical referential by Potter and Perry (2004) on concision and organization we have found 114 (100%) inadequate nursing record. Thus, it has been verified that there is deficiency in the elaboration of the nursing staff, which is nor not correct neither in ethical in legal aspects.
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Al-Kuwari, Wasmiya Dalhem M. D. "Information management within the Nursing Department at Hamad Medical Corporation (HMC), Qatar." Thesis, Loughborough University, 2005. https://dspace.lboro.ac.uk/2134/7811.
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Hamad Medical Corporation, the main healthcare provider in the state of Qatar, sponsored this study to investigate the use of electronic records management as the basis for a novel information management system in its Nursing Department. To assess the viability of an electronic records management system a questionnaire survey of a representative sample of the staff and interviews with key post holders were under taken. Results obtained indicated a wide spread dissatisfaction with the existing manual system. However, introduction of any computer-based technology requires great care. To assist with identifying any issues with this technological change, Soft System Methodology (SSM) was employed to discern what changes could be made to improve the current problematic situation found in the Nursing Department. In fact the change archetypes uncovered (procedural, attitudinal, structural and cultural) formed an innovative input into obtaining a roadmap for development of the electronic staff records system. This roadmap was facilitated by the use of Nominal Group Technique (NGT) and Interpretive Structural Modelling (ISM): In fact the roadmap was an ISM intent structure. The roadmap suggested that change could be affected by having written policy documents and the top goal to be achieved reflected an improvement in manpower placing and budgetary forecasts. The use of a multi-methods approach meant that as well as this study's main objectives being reached, the process encompassed some methodological innovations. This study is the first to use the output of SSM to facilitate the NGT and ISM interactions. Equally, it is the first study of its sort to be applied to the Nursing Department at HMC, Qatar, which is an example of a cross-cultural eastern philosophical tradition. The methods used here revealed some significant findings, and have helped in the development of an electronic records management system for use at HMC, Qatar.
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Cheung, Hor-wan Annemarie. "Perceived gender differences in nursing in Hong Kong." Click to view the E-thesis via HKUTO, 2004. http://sunzi.lib.hku.hk/hkuto/record/B31972883.
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Henriques, Hugo. "Inovação na qualidade dos registos de enfermagem no sistema de apoio à prática de enfermagem." Master's thesis, Instituto Politécnico de Setúbal. Escola Superior de Saúde, 2016. http://hdl.handle.net/10400.26/17274.
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Relatório de Trabalho de Projeto apresentado para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Enfermagem Médico-CirúrgicaOs registos são parte integrante do processo de enfermagem, sendo um forma de justificar e comprovar os cuidados prestados aos doentes. De igual forma são uma fonte de informação e um meio de comunicação, constituindo um instrumento de trabalho essencial para a pratica de enfermagem. Os registos em SAPE têm várias vantagens nomeadamente facilitar o planeamento de cuidados, garantir a sua continuidade, avaliar a eficácia das intervenções entre outras. O objetivo deste relatório visa demonstrar o percurso realizado para a implementação do projeto de intervenção em serviço sobre a inovação na qualidade dos registos de enfermagem na Unidade de Cuidados Diferenciados Imediatos. Para atingir o objetivo delineado no âmbito do projeto de intervenção em serviço, recorreu-se à metodologia de projeto por forma a fazer o diagnóstico de situação, planeamento do projeto e a sua avaliação. No decorrer do estagio também se realizou um projeto de aprendizagem de competências que consitiu na aquisição e desenvolvimento de competências especializadas, tendo como referencial os documentos publicados pela Ordem dos Enfermeiros no que respeita ao enfermeiro especialista em enfermagem médico-cirúrgica e às competências de mestre. Durante a realização dos estágios o projeto de intervenção em serviço relativamente à qualidade dos registos de enfermagem não pode ser concluído por razões externas ao curso de mestrado, no entanto o diagnóstico de situação e planeamento efetuado fora aceites pelo serviço e serão implementados posteriormente. No que respeita às competências de enfermeiro especialista e de mestre o caminho efetuado ao longo dos estágios permitiram a aquisição destas competências.
The records are an integral part of the nursing process, as a way to justify and prove the care of patients. Likewise are a source of information and a means of communication, is an essential working tool for the practice of nursing. Records in SAPE have several advantages particular to facilitate the planning of care, ensure their continuity, evaluate the effectiveness of interventions among others. The objective of this report is to show the route taken in the implementation of service intervention project on innovation in the quality of nursing records in Unidade de Cuidados Deferenciados Imediatos. To achieve the objective outlined in the intervention project in service, appealed to the design methodology in order to make the diagnosis of the situation, project planning and evaluation. During the stage also held a learning project skills that had consisted in the acquisition and development of expertise, as reference documents published by the Order of Nurses in relation to specialist nurse in medical-surgical nursing and master skills. In carrying out the stages intervention project in service on the quality of nursing records can not be completed for reasons external to the master's course, however the diagnosis of the situation and planning carried out by the service accepted and will be implemented later. With regard to nurse specialist skills and master the path made through the stages allowed the acquisition of these competencies
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Carrijo, Alessandra Rosa. "Registros de uma prática: anotações de enfermagem na memória de enfermeiras da primeira escola nightingaleano no Brasil (1959 - 1970)." Universidade de São Paulo, 2007. http://www.teses.usp.br/teses/disponiveis/7/7131/tde-17052007-095948/.
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O presente estudo foi elaborado a partir dos depoimentos orais de sete enfermeiras, sendo uma ex-diretora e seis ex-alunas, da Escola de Enfermagem Lauriston Job Lane, do Hospital Samaritano, criado em 1894, na cidade de São Paulo. Essa instituição de ensino funcionou de 1959 a 1970. Os depoimentos revelaram inúmeras situações vividas por essas mulheres inseridas em uma categoria profissional historicamente identificada como feminina, vale dizer, a Enfermagem. Teve como objetivos: apresentar como essas narradoras vivenciaram o processo de sua formação profissional nessa escola, revelando como os registros (anotações) de enfermagem eram ensinados e realizados na década de 1960. Os dados coletados nas entrevistas foram analisados com base nas propostas da Análise de Conteúdo de Bardin (1977) e Minayo (1989), distribuídos em duas principais categorias: Trajetória Acadêmico-Profissional das Colaboradoras e Registros de Enfermagem - Histórico dos Registros. A discussão sobre os registros de enfermagem torna-se relevante na medida em que a formação profissional privilegia a técnica, sobrepondo os conteúdos dos fundamentos da enfermagem, negligenciando, em muitos casos, a teorização do cuidado. Pelo conteúdo dos depoimentos orais foi possível identificar a importância das anotações de enfermagem para uma assistência de qualidade, suas características e transformações ao longo dos temposThis study was written based on oral statements of seven nurses, being one ex-dean and six nurses, of the Nursing School Lauriston Job Lane, Samaritan Hospital, created in 1894, in the São Paulo city. This educational institution has functioned from 1959 to 1970. Statements showed several situations experienced by those women inserted within a category which is historically identified as feminine, that is, nursing. Objectives of the study were: to present how those narrators have experienced their professional education process within this school and disclosing how nursing records were taught and made in the 60´s. Collected data through interviews were analyzed based on Content Analysis proposed by Bardin (1977) and Minayo (1989), distributed in two categories: collaborators´ professional and academic trajectory and nursing records´ historical registration. A discussion on nursing records becomes relevant while professional education privileges the technical one, overlaying contents of fundamentals of nursing, neglecting in many cases the care theorizations. Through those contents of oral statements it was possible to identify the importance of nursing records for a quality care, their characteristics and changes brought along time
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Hultin, Dojorti Sandra. "Omvårdnads-dokumentation för patienter med höftfraktur : - En retrospektiv journalgranskning." Thesis, Umeå universitet, Institutionen för omvårdnad, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-183980.
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Bakgrund: Kvaliteten på sjuksköterskans omvårdnadsjournal kan återspegla den vårdkvalitet som tillhandahålls patienter. Patienter med en höftfraktur har ofta ett omfattande vårdbehov där omvårdnadsjournalen har en viktig funktion att strukturera dokumentation av vårdinsatser genom patientens vårdförlopp. Patienter med höftfraktur har ofta en komplex sjukdomsbild, där omvårdnadsdokumentationens kvalitet kan bidra till en säkrare vård för patienten. Kvaliteten på dokumentationen ökar vid en strukturerad journal och framförallt när ett standardiserat språk används. Journalgranskning är ett sätt att göra kvalitetskontroll av dokumentation. Motiv: Att drabbas av en höftfraktur innebär stora hälsorisker för en ofta redan skör person. Omvårdnadsdokumentationens kvalitet vid höftfraktur kan bidra till att patienten får bättre förutsättningar för att undvika komplikationer och till kortare vårdtid. Syfte: Att undersöka kvaliteten av omvårdnadsdokumentation för patienter med höftfraktur.Metod: En retrospektiv, deskriptiv och jämförande design där granskning av omvårdnadsjournaler användes för att besvara studiens syfte. Ett konsekutivt urval har gjorts av omvårdnadsdokumentation från 40 vårdtillfällen med patienter över 60 år som vårdats för en höftfraktur på en akutortopedisk avdelning. För granskningen användes journalgranskningsinstrumentet Cat-ch-ing. Resultat: De granskade omvårdnadsjournalernas kvalitet var varierande; ingen av journalerna hade en komplett dokumentation. Dokumentation av vårdplan och resultat av omvårdnadsåtgärder saknades i en majoritet av journalerna. Dokumentationen var av bättre kvalitet i gruppen yngre äldre patienter vid jämförelse med gruppen äldre äldre patienter. Ingen skillnad av kvalitet i dokumentationen kunde urskiljas utifrån vårdtidens längd då patienter som vårdats mindre än sju dygn eller sju dygn eller mer jämfördes. Konklusion: Kvaliteten av omvårdnadsdokumentationen var inte komplett. Det krävs ytterligare kunskap om förbättringsåtgärder i den kliniskas verksamheten för att säkerställa en omvårdnadsdokumentation av god kvalitet där patienter med höftfraktur vårdas.Background: The quality of the nursing record can reflect the quality of nursing care provided to patients. Patients with a hip fracture often have an extensive need for care. The nursing record has an important function of describing the nursing process, nursing diagnoses and interventions. Patients with hip fractures often have complex health care needs and the nursing documentation can contribute to patient safety. The quality of the documentation increases with a structured journal. Furthermore, it should be written in a standardized language. Audit of nursing documentation can contribute to quality of care. Motive: Great health risks is a fact when suffering from a hip fracture, especially an already fragile person. The quality of the nursing documentation can contribute to better outcome in patient safety and the length of stay. Aim: To explore the quality of nursing documentation for patients with hip fractures. Methods: A retrospective descriptive and comparative design where audit of nursing records was used to attain the study's aim. A consecutive sample was used, where 40 patients’ health care records of nursing documentation for patients over the age of 60 with a hip fracture in an emergency orthopedic ward were included. The audit instrument Cat-ch-Ing was used. Result: The result showed that the quality was variable; none of the records had a complete documentation. Documentation of care plans were missing in a majority of the records. The documentation was of better quality in the group of younger elderly patients compared to that of older elderly patients. No quality differences were seen based on the length of stay. Conclusion: None of the records had a complete documentation. Further knowledge of how good quality nursing documentation on hip fractur patients can be implement for a sustainable result in clinical activities.
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Ribeiro, Floracy Gomes. ""Estudo comparativo de dois métodos de registro de diagnósticos e intervenções de enfermagem em pacientes durante o transoperatório de cirurgia de revascularização do miocárdio"." Universidade de São Paulo, 2006. http://www.teses.usp.br/teses/disponiveis/5/5156/tde-25082006-093907/.
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Este trabalho teve como objetivo comparar as freqüências e concordâncias em percentual os registros de diagnósticos e intervenções de enfermagem entre dois métodos: Sistematização de Assistência de Enfermagem (SAEP) e o Conjunto de Dados de Enfermagem Perioperatória (PNDS) no transoperatório de RM, Os métodos foram empregados por 2 grupos distintos de enfermeiros em 50 pacientes. Os registros encontrados no SAEP foram transcritos, mapeados para o PNDS e então comparados. No PNDS registrou-se 648 diagnósticos e no SAEP 38. A freqüência de intervenções registradas para o PNDS foi 1863 e para SAEP 1587. Não houve concordância em percentual para a presença de diagnósticos entre os métodos estudados. Nas intervenções do domínio segurança, houve concordância acima de 70% em 12 categoriasThis study aimed to compare frequency and percentage agreement of nursing diagnosis and interventions documented by two different methods: Perioperative Nursing Care Process (SAEP) and Perioperative Nursing Data Set (PNDS) during intra-operative CABG surgery. The methods were employed by two distinct groups of nurses with 50 patients. SAEP nursing documentation was transcribed, mapped and compared to PNDS. With the PNDS documentation, 648 nursing diagnosis were recorded and 38 with SAEP. Nursing interventions frequency for PNDS were 1863 and SAEP, 1587. There was no percentage agreement of nursing diagnosis between the studied methods. There was over 70% agreement for safety domain interventions, in 12 categories
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Johnson, C. Frances. "An assessment of a training program designed to teach staff nurses in an acute care facility to transfer nursing process theory to practice." PDXScholar, 1985. https://pdxscholar.library.pdx.edu/open_access_etds/417.
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A training program was developed to help registered nurses in an acute care facility to learn nursing process theory and to transfer that theory to nursing practice. A total sample of 102 newly-hired nurses who had participated in this training program were pre- and post- tested on class content; they also filled out a questionnaire which provided demographic and attitudinal data related to the use of nursing process as a model for nursing care. An audit sample of 82 nurses, who were a part of the total sample, were audited one month after the training program to collect data on documentation in patients' charts of the understanding and utilization of nursing process; 246 audits were completed. Concomitantly, an audit was performed to determine total nursing staff compliance with requirements that the nursing process be used and documented in patients' charts. Performance behaviors, i.e., pre- and post-test scores, common test scores, self-perceived understanding scores, and percent complete on audit were collected and analyzed. Additionally, data on age, experience, and type of nursing education were collected and analyzed. Results indicated that the nurses who attended this training program evidenced an understanding of nursing process theory and documented their implementation of the process into nursing practice. Despite differences in age, experience, and educational programs which appeared to be statistically significant, the performances of nurses who had attended this training program showed no significant differences in practice.
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Sesay, Nanah Sheriff. "Development of an Electronic Health Record Educational Project for Staff Nurses." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/1214.
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Abstract
The use for electronic health records (EHRs) by 2015 is being mandated through incentive payments for health care providers. Evidence-based literature has shown that almost half of the hospitals in the Unites States have not adopted EHRs, and many nurses have not been educated to effectively use them. In order to enhance and sustain EHR adoption by hospitals, nurses need to be educated on EHRs' usability. The purpose of this project was to develop an evidence-based EHR educational project for nurses on how to enter nursing assessments, document patients' medical data, and communicate effectively with patients and health care providers. The development of this educational project was guided by Ajzen's theory of planned behavior.
An advisory committee of 5 members determined the effectiveness and usefulness of the project. The advisory committee was comprised of the director of nursing, the director of information technology, a nurse manager, a nursing informatics specialist, and a staff nurse. Findings from the advisory committee indicated the project was in alignment with the objectives for meaningful use of EHR adoption by hospitals, conformed to the quality standards established by the agency for which this project was developed, and provided educational materials that were helpful in enhancing staff nurses understanding of EHR usability. In addition, feedback from the nurses who reviewed the educational project indicated that they were concerned about frequent upgrades and customization that were being made in Epic and the project was useful in enhancing staff nurses understanding of Epic usability. This project has the potential of increasing staff nurses' efficiency in using the Epic EHR system.
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Moraes, Jéssica Amici. "Registros das ações de enfermagem relacionadas ao reposicionamento dos pacientes e à prevenção da lesão por pressão em uma unidade de terapia intensiva." Universidade de São Paulo, 2018. http://www.teses.usp.br/teses/disponiveis/22/22132/tde-24042018-192954/.
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Os registros no prontuário do paciente são ferramentas estratégicas para o gerenciamento da qualidade da assistência em saúde e enfermagem. A Lesão por Pressão caracteriza-se como um indicador de qualidade assistencial e gerencial, permitindo a implementação de ações preventivas, por meio da utilização de diretrizes e protocolos clínicos destinados a orientar os profissionais de saúde para o alcance de uma assistência livre de danos. O objetivo deste estudo foi analisar o conteúdo dos registros das ações de enfermagem relacionadas ao reposicionamento dos pacientes em uma unidade de terapia intensiva. Trata-se, portanto, de estudo quantitativo, longitudinal, correlacional e analítico. A coleta de dados foi conduzida após aprovação do Comitê de Ética em Pesquisa e a amostra foi composta por 37 pacientes que atenderam aos critérios de inclusão da pesquisa. Quanto às características sociodemográficas e clínicas, foi identificado como maioria, o sexo masculino (56,8%); brancos (78,4%), na faixa etária de 60 a 79 anos (48,6%) e o tempo médio de internação na unidade com predominância de até dez dias de permanência (57,9%). A maioria dos indivíduos (48,6%) apresentou risco elevado para a Lesão por Pressão, com média de 11,7%; escore médio de gravidade de 54% na admissão e 54% na alta. Do total, 35,1% apresentou Lesão por Pressão, notificada no sistema de informação hospitalar, e 43,2% evoluiu para óbito. Na análise dos escores de risco para Lesão por Pressão (Braden) e gravidade na entrada (APACHE-E) e na saída (APACHE-S) da UTI, segundo o sexo, LP notificada e evolução para óbito entre os participantes da pesquisa, foram identificados valores estatisticamente significantes, exceto, entre as variáveis Braden e Lesão por Pressão notificada. Na análise dos valores percentuais de registros de ações de reposicionamento dos pacientes, segundo Lesão por Pressão notificada e evolução para óbito, não foram identificados valores estatisticamente significantes. Foi identificada correlação negativa (-0,369) e significância estatística (p=0,024) entre o percentual de registros de ações de reposicionamento e o escore Braden, ou seja, os pacientes com maior risco para Lesão por Pressão apresentaram maior frequência de registros de ações de reposicionamento. Na análise do conteúdo dos registros realizados diariamente pela equipe de enfermagem no prontuário do paciente, foi verificada predominância de registros relacionados à descrição da posição do paciente no leito e reposicionamento do paciente sem especificar a posição adotada. Este estudo evidencia a importância das informações produzidas pela equipe de enfermagem para identificação de pacientes em risco de desenvolvimento de Lesão por Pressão e o estabelecimento de medidas preventivas que atendam às exigências contemporâneas de maior efetividade, qualidade e segurança na assistência hospitalar, em especial, na unidade de terapia intensiva. Finalmente, vale destacar a relevância da sistematização da assistência de enfermagem, pautada na adoção de linguagem padronizada e estruturada, em suporte de papel ou eletrônico, visando à disponibilização de informação precisa, oportuna, válida, comparável e compartilhável, fundamentada nos pressupostos éticos e legais, políticos e organizacionais que envolvem o processo de auditoria no gerenciamento da assistência em saúde e enfermagemThe records in the patient\'s chart are strategic tools for managing the quality of health and nursing assistance. The Pressure Injury is characterized as an indicator of welfare and management quality allowing the implementation of preventive actions, through the use of clinical protocols and guidelines intended to guide health professionals to achieve a damage-free assistance. The aim of this study was to analyze the contents of the records of nursing actions related to the repositioning of patients in an intensive care unit. It is a longitudinal, quantitative, correlational and analytical study. Data collection was conducted after approval by the Committee of ethics in research and the sample was comprised of 37 patients who met the inclusion criteria. With regard to socio-demographic and clinical characteristics, was identified most of the males (56.8%), whites (78.4%), aged 60 to 79 years (48.6%) and the average time of hospitalization in unit with up to ten days of stay (57.9%). The majority of individuals (48.6%) presented a high risk for Pressure Injury averaging 11.7%, average score for severity on admission of 54% and 54% on high. Of the total, 35.1% presented notified Pressure Injury in hospital information system and 43.2% evolved to death. In the analysis of the risk scores for Pressure Injury (Braden) and gravity at the entrance (APACHE-E) and outlet (APACHE-S) of the ICU second sex, notified PI and evolution to death among the participants of the survey, statistically significant values were identified, except between Braden and variables notified Pressure Injury. In the analysis the percentage values of stock records of repositioning of patients according to notified Pressure Injury and evolution to death were not identified statistically significant values. It was negative correlation (-0.369) and statistical significance (p = 0.024) between the percentage of stock records of repositioning and the Braden score, i.e., patients with increased risk for Pressure Injury presented a higher frequency of stock records of repositioning. In the analysis of the content of the records held daily by the nursing staff in patient records, was observed a predominance of records related to description of the position of the patient in the bed and repositioning of the patient without specifying the position adopted. This study highlights the importance of information produced by the nursing staff to identify patients at risk for developing Pressure Injury and the establishment of preventive measures that meet the contemporary requirements of greater effectiveness, quality and safety in the hospital, in particular, in the intensive care unit. Finally, it is worth highlighting the relevance of systematization of nursing care, based on the adoption of standardized and structured language, in paper or electronic support, aimed at the provision of accurate information, timely, valid, comparable and sharable, based on ethical and legal assumptions, organizational and political involving health assistance management and nursing
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Kaewprag, Pacharmon Fuhry. "Visual Analysis of Bayesian Networks for Electronic Health Records." The Ohio State University, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=osu1531778349031686.
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Lemos, Lucimeire Fermino. "Análise dos registros de curativos em prontuários de um hospital de ensino do Estado de Goiás." Universidade Federal de Goiás, 2016. http://repositorio.bc.ufg.br/tede/handle/tede/6268.
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Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG
Health records are important for keeping effective communication among all professionals involved in the process of taking care as well as for legitimating the team actions in the face of patients and families. The records must be clear and objective because they are sources of information for judicial, research, teaching, billing and auditing issues. This study has an objective to analyze the records of procedures of Level II Curative in medical records of hospitalized patients, from the nurses’ perspective, before and after the pedagogical intervention, in a Brazilian teaching hospital in the Midwest region. It was a descriptive study with both qualitative and quantitative research and was developed in many stages. The first stage included the nurses’ profiles and the identification of the main reasons why the nursing actions were not recorded. The second stage was the analysis of the records before and after the pedagogical action, which was the third stage. At last, the nurses were interviewed about their perception of the importance of the records for billing. It was observed among the sample of nurses the predominance of women (87,2%), post-graduated (82,1%) and statuary civil servants (80,4%). Even though 53,6% of the nurses said that they do not have double employment relationships, 46,4% said they do. The nurses said that it was not possible to record the procedures due to lack of time (50%), work overload (20%), lack of human resources and access to the records (12,5%), interruptions and lack of guidance (2,5%). The objective of the intervention was to discuss the importance of health records, and specially, in relation to the level II curative. 45,2% of the nurses of this institution took part in this event. In the analysis of the records, before and after the intervention, it was possible to observe the increase of the records of the curatives (82,3%), the detailing of the quantity of curatives per patient (69,9%), the classification of the wounds (63,5%), the description of the materials used in the procedures (67,3%), and also the scheduling (74%) and the checking (71,4%). The data shows that the quantity of material used maintained still. However, there was a rise of curative prescription by the nurses (79,4%) and a fall of curative prescription by the doctors (18,3%). It was also possible to observe that the performed and not prescribed procedures or prescribed and not verified procedures, in both cases, were not billed. Nevertheless, the hospital overturn related to this procedure has an increase, from July 2015. The interviews with the nurses showed that they take the responsibility in the treatment of wounds for themselves. However, it is necessary to standardize the prescriptions and the evolutions of the procedure. The complete record of this intervention is important to safeguard the institution in case of auditing. In conclusion, nurses have an important role in recording the wound treatment. The obligation of recording should be reinforced due to the quality of the service and the profession´s visibility as well as for a better material and input control and billing.
Os registros em saúde são importantes tanto para garantir comunicação efetiva entre todos os profissionais envolvidos no processo de cuidar, quanto para legitimar as ações da equipe junto ao usuário e família. Devem ser claros, e objetivos, pois servem de fonte de informações para questões jurídicas, de pesquisa, ensino, faturamento e auditoria. Este estudo teve por objetivo analisar os registros do procedimento curativo (curativo grau II) nos prontuários de pacientes internados, em um hospital universitário de Goiás, na perspectiva dos enfermeiros, antes e após um treinamento, em hospital de ensino da região Centro-Oeste do Brasil. Tratouse de estudo descritivo, de natureza mista, quanti-qualitativa, desenvolvido em várias etapas. A primeira etapa compreendeu a caracterização do grupo de enfermeiros e a identificação dos principais motivos para a falta de registro das ações de enfermagem. Na segunda etapa, a análise do prontuário procurou em dois momentos, antes e após ação educativa (terceira etapa), identificar o registro. Por último, em entrevista com enfermeiros, verificou-se sua percepção quanto à importância dos registros para o faturamento. Na amostra dos enfermeiros, observou-se predominância feminina (87,2%), de pós-graduados, (82,1%), com vínculo estatutário (80,4%). Embora 53,6% tenham alegado não ter duplo vínculo empregatício, chama a atenção 46,4% alegarem esta condição. Os enfermeiros referem ainda que nem sempre é possível a efetuação dos registros, relatando como motivos: falta de tempo (50%), sobrecarga de trabalho (20%), falta de recursos humanos e acesso à papeleta (12,5%), e interrupções e falta de orientação (2,5%). Realizou-se atividade interventiva, que teve por objetivo tratar de assunto referente à importância do registro em saúde, e especificamente em relação ao curativo grau II, e contou com a participação de 45,2% dos enfermeiros desta instituição. A análise dos prontuários antes a após a intervenção, verificou o aumento dos registros de prescrição de curativos (82,3%), discriminação da quantidade de curativos por paciente (69,9%), classificação das feridas (63,5%), descrição dos materiais utilizados (67,3%), além do aprazamento (74%) e checagem (71,4%). Não se verificou alteração relacionada ao registro da quantidade de materiais. Evidenciou-se aumento das prescrições do procedimento por enfermeiros (79,4%) e diminuição pelos médicos (18,3%). O estudo permitiu ainda identificar procedimentos executados e não prescritos ou prescritos e não checados, em ambos os casos não faturados. Apesar disto, o faturamento do hospital, no que se refere a este procedimento, apresentou aumento a partir de julho de 2015. A entrevista com enfermeiros evidenciou que este profissional assume para si a responsabilidade do tratamento de feridas, mas ainda é necessária a padronização das prescrições e evoluções referentes a este cuidado. O registro completo da intervenção é importante para que a instituição se resguarde em caso de auditoria. O enfermeiro tem papel importante no registro do tratamento de feridas. Deve ser reforçada a obrigatoriedade do registro, tanto para a qualidade do atendimento prestado e visibilidade da profissão, quanto para o melhor controle de materiais e insumos e do faturamento relacionado a este procedimento.
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Clausson, Eva. "SCHOOL HEALTH NURSING : Perceiving, recording and improving schoolchildren’s health." Doctoral thesis, Nordic School of Public Health NHV, 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:norden:org:diva-3479.
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Aim: The overall aim of this thesis is to explore School health nursing through school nurses’ descriptions of schoolchildren’s health and to analyse factors influencing the recording of school-children’s health in the School Health Record (SHR). An additional aim is to evaluate fam-ily nursing interventions as a tool for the school nurses in the School Health Service (SHS). Methods: The thesis comprises four papers. A combination of qualitative and quantita-tive methods was used through individual interviews with a strategic sample of school nurses (n=12) (PI), a national survey to a representative sample of school nurses (n=129) (PII, III) and the implementation of family nursing models developed in Canada with girls in their early ad-olescence with recurrent health complaints and their families (n=4) in co-operation with their school nurses (n=2) (PIV). The Strengths and Difficulties Questionnaire (SDQ) was used as pre and post test. Evaluation interviews were conducted with the families and the nurses separate-ly. Qualitative content analyses were used to analyze the interview text with the school nurs-es and the families. Manifest content analysis was used to analyze the free text answers of the survey and the evaluation interview with the school nurses. Descriptive statistical analyses were used to describe demographic data in all four papers. The SDQ was hand-scored statistically. Findings: The findings showed that nurses judged the schoolchildren’s mental health as dete-riorated, especially in socially disadvantaged areas and more generally among girls expressed as psychosomatic symptoms. Individual factors related to lifestyle affected the schoolchildren’s physical health, and the mental health was, to a large extent, affected by the school environ-ment and family relations. The latter seemed to be the most important factor affecting school-children’s mental health. The basis for the school nurses judgement of the physical health was health check-ups and the health dialogues. Spontaneous visits were more commonly used to judge the mental health. Recording schoolchildren’s mental health was a challenge for school nurses. Difficulties were related to ethical considerations, tradition, lack of time and the im-proper structure of the SHR. Fears of marking the schoolchild for life related to the schoolchild itself, the parents or to other authorities/successive caregivers were brought up as hinders for recording mental and social health. Family sessions may be useful within the profession when handling recurrent health complaints among adolescence girls. The girls and their families ex-perienced relief, they felt confirmed and that their feelings and reactions were normal in that situation. The families became aware of their own strengths and possibilities and this was sup-ported by the SDQ which showed an increased well-being. The school nurses valued this way of working and meant that the sessions seemed to start a changing process within the families. Conclusions: The results indicate that school nurses have a deep knowledge about schoolchil-dren’s health which is not used to its full potential in a public health perspective. However, the experienced difficulties recording schoolchildren’s mental health seem obvious, which would de-mand developing the SHR for the needs of today. Family sessions in SHS with the school nurse as a collaborator with the family seemed useful and may be transferable to other health problems expressed by the schoolchildren. Bronfenbrenner’s ecological systems theory and other models for health determinants are used to illustrate the school nurse as a mediator working on the bridge over different health streams with schoolchildren’s health on an individual and a population level.
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Brito, Nilza Martins Ravazoli [UNESP]. "Conjunto de dados mínimos de enfermagem para unidade de internação clínica." Universidade Estadual Paulista (UNESP), 2017. http://hdl.handle.net/11449/151094.
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Introdução: O Conselho Federal de Enfermagem (COFEN), por meio da Resolução 358/2009, preconiza que a assistência de enfermagem deve ser sistematizada com a implementação do Processo de Enfermagem (PE). O PE direciona os julgamentos clínicos ao cuidado de enfermagem. Um dos desafios dos profissionais da enfermagem é o uso de um sistema de classificação na prática do cuidado, aliada a recursos tecnológicos disponibilizados pelos Registros Eletrônicos de Saúde (RES). Os RES estruturados a partir de um Conjunto de Dados Mínimos de Enfermagem (CDME) e sistemas de classificação de enfermagem podem contribuir à construção de Sistemas de Informação em Saúde de melhor qualidade. Objetivos: Construir um CDME para unidade de internação clínica. Métodos: Estudo metodológico desenvolvido em quatro etapas. Na primeira etapa, foi realizada a análise documental dos formulários e telas do sistema de informação, utilizados na unidade de clínica médica para registro de enfermagem, de um hospital público do interior do Estado de São Paulo. Na segunda etapa, foram realizadas oficinas com enfermeiros da unidade de clínica médica para determinar o conjunto de dados mínimos de enfermagem, relacionados aos elementos dos cuidados de enfermagem, elementos do paciente e elementos dos provedores de serviços, pertinentes à assistência de enfermagem, tendo como referenciais a classificação de diagnósticos de enfermagem NANDA Internacional (NANDA-I), a Classificação das Intervenções de Enfermagem (NIC) e a teoria de enfermagem das Necessidades Humanas Básicas (NHB). Na terceira etapa, foi realizado mapeamento cruzado entre as prescrições de enfermagem da instituição e intervenções da NIC, validadas pela opinião de expertos em PE. Na quarta etapa, foi construído instrumento para registro de enfermagem em RES, considerando o CDME obtido. Os dados foram analisados pelos referenciais da NANDA-I, da NIC e da teoria das NHB. Resultados: Entre os dados analisados dos formulários, telas eletrônicas e opinião dos enfermeiros os dados de enfermagem foram predominantemente do domínio fisiológico da NANDA-I (66%) e da categoria psicobiológica das NHB (86,4%). Os diagnósticos de enfermagem identificados foram predominantemente do domínio fisiológico (48,4%), assim como das prescrições de enfermagem (56,9%). No mapeamento cruzado entre a lista de prescrições de enfermagem e intervenções da NIC, foram avaliados 256 itens de prescrição, entre estes, o domínio fisiológico básico (38,9%) e complexo (44%) foram predominantes. No mapeamento cruzado, todos os itens tiveram concordância superior a 80% entre os expertos. Partindo dos resultados, foi construído um instrumento de CDME para RES e um ebook. Conclusão: O CDME foi construído com dados utilizados por enfermeiros na assistência e o seu uso reflete a prática assistencial em unidade de internação clínica, favorece a qualidade na construção de RES para registro de enfermagem e oferece indicadores de qualidade assistenciais e gerenciais.
Introduction: By means of Resolution 358/2009, the Brazilian Nursing Federal Council (COFEN) recommends that the nursing care should be systematized through the implementation of the Nursing Process (NP). The NP guides the clinical judgments needed in nursing care. One of the greatest challenges faced by nursing professionals in this process is the use of a classification system in the practice of care, together with technological resources provided by the Electronic Health Records (EHR). These EHR, when structured from a Nursing Minimum Data Set (NMDS) and from nursing classification systems, can contribute to the quality development of Health Information Systems. Objectives: To develop a NMDS for clinical hospitalization units. Methods: Methodological study performed in four stages. At the first stage a documentary evaluation of the screens and forms of the information system used at the clinical unit to register nursing data in a public hospital of the State of São Paulo was conducted. At the second stage, workshops were held with nurses from the medical unit to determine the NMDS related to the nursing care elements, patient elements and to the service providers elements involved in nursing care. It was used as referential the nursing diagnoses classification NANDA International (NANDA-I), the Nursing Intervention Classification (NIC) and the nursing theory Basic Human Needs (BHN). At the third stage, a cross-mapping was made between the nursing prescriptions from the institution and the nursing interventions from the NIC, validated by experts in NP. Finally, at the fourth stage an instrument to support the nursing EHR was developed, according to the obtained NMDS. The data were analyzed by the referential NANDA-I, NIC and BHN theory. Results: Among the analyzed data of the forms, electronic screens and nurses' opinion the nursing data were predominantly about the physiological domain of NANDA-I (66%) and about the psychobiological category of the BHN (86.4%). The nursing diagnoses identified were predominantly in the physiological domain (48.4%), as well as in nursing prescriptions (56.9%). In the cross-mapping between the list of nursing prescriptions and NIC interventions, 256 prescription items were evaluated, among which the predominant basic physiological domain (38.9%) and complex (44%). In this cross-mapping all items had an agreement rate higher than 80% among experts. Based on these results, a NMDS instrument was developed for HER and an ebook. Conclusion: The NMDS was developed based on data used by nurses during nursing care and its use reflect nursing care in clinical hospitalization unit, brings quality in the construction of EHS for nursing registration and provide management and care quality indicators.
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Maxwell, Karen Elizabeth. "Designing the Plane While Flying It: A Case Study on Nursing Faculty Development during Academic Electronic Health Records Integration in a Small Liberal Arts College." PDXScholar, 2014. https://pdxscholar.library.pdx.edu/open_access_etds/1930.
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The expectation of graduating nurses today is to be knowledgeable and responsive to rapidly changing technology in the health care environment. Although federal mandates, Institute of Medicine (IOM) recommendations, and nursing program accreditation initiatives are pushing an "informatics" healthcare agenda by promoting the implementation of electronic health record (EHR) systems by 2014 in all healthcare facilities, very few US nursing schools provide students with access and training in, EHR systems. In addition, nursing faculty may not have a clear understanding of healthcare informatics; the use of information and technology to communicate, manage knowledge, mitigate error, and support decision-making. Nursing education must address faculty issues related to this innovative paradigm in order to keep pace and participate as co-creators of relevant informatics technology curriculum that prepares graduates for real life workforce.
Understanding the challenges, concerns, and successes in implementing informatics may help nurse educators as they develop curriculum and teach in this environment. This case study explores and describes, with nursing faculty of a small liberal arts college, faculty knowledge, skills, and attitudes (KSAs) as they participate in an action research framed curriculum development program for informatics academic EHR (AEHR) integration. The research question:What is the experience of nursing educators and nursing faculty members involved in the integration of an AEHR project framed in the Learning by Developing model at a small liberal arts college school of nursing?
Significant insights as participants in the study influenced nurse educators' ideas regarding collaborative curricular design, meaningful assignments, and the importance of feedback.
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Lam, Sui-sum. "Mandatory continuing nursing education factors influence nurses participation in Hong Kong /." Click to view the E-thesis via HKUTO, 2004. http://sunzi.lib.hku.hk/hkuto/record/B31972949.
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Chan, Kit-lin. "Perceived stress and coping strategies of baccalaureate nursing students in clinical practice." View the Table of Contents & Abstract, 2006. http://sunzi.lib.hku.hk/hkuto/record/B36396941.
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Wong, Hay-tai. "Attitudes of accident and emergency department nurses towards extending and expanding their professional roles in Hong Kong a pilot study /." Click to view the E-thesis via HKUTO, 2003. http://sunzi.lib.hku.hk/hkuto/record/B3197286X.
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Olivier, Johann Marthinus. "Record keeping : self-reported attitudes, knowledge and practice behaviours of nurses in selected Cape Town hospitals." Master's thesis, University of Cape Town, 2010. http://hdl.handle.net/11427/25834.
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Background: South African law holds nurses accountable for their acts and omissions and all documentation pertaining to patient care may serve as evidence in a court of law or at South African Nursing Council (SANC) hearings. Documentation can confirm or refute negligence and therefore should be an accurate and current reflection of what happened to the patient, particularly as litigation often arises long after care was rendered. Objective: To describe the self-reported attitudes towards, knowledge of and practice behaviours of nurses, and the association between these factors and selected variables (category of nurse, gender, hospital sector, years of experience after registration/enrolment, day/night shift and practice discipline) relative to record keeping. Methods: A quantitative, non-experimental study design, using a cross-sectional survey method to describe attitudes, knowledge and practice behaviour against predetermined measurement scales. Stratified random sampling and a questionnaire was used, with a 52.54% (186/354) response rate. Logistic regression models were fitted to determine factors associated with attitudes, knowledge and practice behaviour, fitted as binary dependent variables, each in a separate model. Strength of association was expressed as an odds ratio (OR), and a p-value of 0.05% was considered significant. Setting: Three tertiary Government hospitals and three Private hospitals in the Cape Town Metropole, South Africa. Findings: Demographically, the sample consisted of 92 Registered Nurses (RNs), 42 Enrolled Nurses (ENs) and 50 Enrolled Nursing Auxiliaries (ENAs) of which 94.62% (n=176) were female and 4.30% (n=8) male. The mean age of all respondents were 42.26 years (range 23 to 64) while 48.92% (n=91) of the respondents had more than 15 years of experience after registration/enrolment. Of the 186 respondents, 54.85% (n=102) worked in Government Hospitals, comprising 53 (51.96%) RNs, 25 (24.51%) ENs and 22 (21.57%) ENAs. The 45.16% (n=84) Private Hospital respondents consisted of 39 (46.43%) RNs, 17 (20.24%) ENs and 28 (33.33%) ENAs. Most respondents (18.82%, n=35) worked in Surgical Units and on day duty (70.43%, n=131). A predominantly positive self-reported attitude towards record keeping was evident (71.74%, n=132/184). The negative attitude ratio in the Private sector (58.49%, n=31/53) was larger than in the Government sector (41.51%, n=22/53) (OR=2.049, 95% CI=1.043-4.025, p=0.037). A larger ratio of respondents working day duty reported a negative attitude (60.00%, n=30/50), compared to those working night duty (40.00%, n=20/50) (OR=2.171, 95% CI=1.066-4.423, p=0.033). Although adequate knowledge levels relative to record keeping were reported by the majority of respondents (74.86%, n=137/183), there were some knowledge deficits. Inadequate knowledge level ratios were more evident amongst ENAs (45.65%, n=21/46) when compared to RNs (30.43%, n=14/46) (OR=4.179, 95% CI=1.873- 9.321, p=0.000). Similarly, acceptable levels of self-reported record keeping practice behaviour were evident amongst the majority of respondents (68.31%, n=125/183). A higher ratio of unacceptable practice behaviour was reported by RNs (39.66%, n=23/58) when compared to ENs (34.48%, n=20/58) (OR=2.727, 95% CI=1.266-5.877, p=0.010). The most prominent practice behaviours reported by respondents included making use of a combination of record keeping approaches when keeping records, having regular record keeping audits, having sufficient supervision relative to record keeping, reading what other nurses have written and nurses writing in the progress notes themselves. The three top ranked barriers to effective record keeping were interruptions while keeping records, insufficient time to effectively keep records and a lack of confidence in the ability to keep accurate records. Conclusion: Although respondents, particularly RNs, reported predominantly positive attitudes towards, adequate knowledge of and acceptable practice behaviour relative to record keeping, there are concerns that the deficiencies amongst ENs and ENAs may have serious implications for patient safety for both the Government and Private Health sectors. Significance to clinical practice: Deficiencies relative to record keeping attitudes, knowledge and practice behaviours were identified. The identified deficiencies could be used to implement record keeping improvement strategies.
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Fontes, Cassiana Mendes Bertoncello. "Perfis de diagnósticos de enfermagem antes e após a implementação da classificação da NANDA-I." Universidade de São Paulo, 2006. http://www.teses.usp.br/teses/disponiveis/7/7139/tde-02062006-104510/.
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O objetivo deste estudo foi analisar os perfis de diagnósticos de enfermagem e dos domínios da classificação antes e após a implementação da classificação da North American Nursing Diagnosis Association International (NANDA-I) na Clínica Médica do Hospital Universitário da Universidade de São Paulo (HU-USP), realizada entre os anos de 2001 e 2004. A amostra foi composta pelos registros de enfermagem de 31 pacientes admitidos em agosto de 2001 (fase pré, sexo masculino=61,3%, idade média=53,6±20,9 anos, internação por doenças do aparelho circulatório=30%) e de 30 admitidos em agosto de 2004 (fase pós, sexo feminino=60,0%, idade média=60,9±23,1 anos, doenças do aparelho respiratório=30%). Todos os registros de enfermagem das primeiras 24 horas de internação foram manualmente transcritos. Na fase pré foi utilizada a técnica de mapeamento cruzado para inferir os diagnósticos segundo a taxonomia da NANDA-I. Os diagnósticos da fase pós foram transcritos dos registros. Os critérios para incluir os diagnósticos das duas fases para as análises finais foram: consenso de painel de três juízes e a existência de pelo menos um item de prescrição de enfermagem pertinente. As associações entre as freqüências de diagnósticos, domínios e as fases do estudo foram testadas, com nível de significância ?0,10. Os perfis de diagnósticos e domínios foram descritos pela Análise Fatorial Múltipla (AFM). Na fase pré, os diagnósticos mais freqüentes foram: integridade da pele prejudicada (54,8%), dor aguda (48,4%) e risco para integridade da pele prejudicada (45,2%), e na fase pós: dor aguda (66,7%), integridade tissular prejudicada (32,3%) e desobstrução ineficaz de vias aéreas para (43,3%). Seis diagnósticos apresentaram diferença estatística entre as duas fases: integridade da pele prejudicada (de 54,8% para 33,3%, p=0,092); nutrição desequilibrada: menos que as necessidades corporais (de 25,8% para ausência de ocorrência, p=0,005); deambulação prejudicada (de 19,4% para nenhuma ocorrência, p=0,024); proteção ineficaz (de nenhuma ocorrência para 23,3%, p=0,005); perfusão tissular renal (de nenhuma ocorrência para 16,7%, p=0,024); ansiedade (de nenhuma ocorrência para 13,3%, p=0,053). Foram identificados seis domínios na fase pré e sete na pós. Houve diferenças significativas nos domínios: conforto (de 48,3% para 73,3%, p=0,046); nutrição (de 25,8% para 6,6%, p=0,023) e enfrentamento/tolerância ao estresse (de nenhuma ocorrência para 13,3%, p=0,053). Essas diferenças indicam que, após a implementação da classificação, houve maior focalização de respostas de conforto e de enfrentamento e tolerância ao estresse. A AFM indicou diferentes perfis de diagnósticos e de domínios entre as fases, mostrando que na fase pós houve maior amplitude dos fenômenos focalizados pelas enfermeiras. A implementação da classificação da NANDA-I contribuiu para ampliar o foco do cuidado, aumentando a ênfase em fenômenos pouco documentados, como os do domínio de enfrentamento e tolerância ao estresse. O fato de as enfermeiras documentarem esses fenômenos como diagnósticos aumenta a responsabilidade na seleção de intervenções adequadas e na avaliação dos resultados obtidos. Os resultados deste estudo são contribuições importantes para aprimorar os processos de implementação das classificações e para monitorar os seus efeitos na prática clínica de enfermagem.The aim of this study was to analyze the profiles of nursing diagnoses and domains of the classification before and after the implementation of NANDA-I (North American Nursing Diagnosis Association International) in the Medical Clinic of the Hospital Universitário da Universidade de São Paulo (HU-USP), carried out from 2001 to 2004. The sample was composed by the nursing records from 31 patients admitted in August 2001 (pre-implementation phase, male=61.3%, mean age=53.6±20.9 years old, admittance due to circulatory system diseases=30%) and from 30 patients admitted in August 2004 (phase post, female=60.0%, mean age=60.9±23.1 years old, respiratory system diseases=30%). All nursing records from the first 24 hours of admittance were manually transcribed. In the phase pre the cross-mapping technique was applied in order to infer the diagnoses according to the NANDA-I taxonomy. The phase post diagnoses were transcribed from the records. The analysis criteria to include the diagnoses from both stages were: a three-referee panel consensus and the existence of at least one pertinent nursing order item. The associations among the diagnose frequencies, domains and study phases were tested, with a significance level of ?0.10. The profiles of diagnoses and domains were described by the Multiple Factorial Analysis (MFA). In the phase pre, the most frequent diagnoses were: skin integrity impaired (54.8%), acute pain (48.4%) and skin integrity impaired risk (45.2%), and in the phase post: acute pain (66.7%), tissue integrity impaired (32.3%) and airway clearence innefective (43.3%). Six diagnoses had statistic difference between the two phases: skin integrity impaired (from 54.8% to 33.3%, p = 0.092); unbalanced nutrition: less than the body requirement (from 25.8% to non-occurrence, p = 0.005); impaired walking (from 19.4% to non-occurrence, p = 0.024); ineffective protection (from non-occurrence to 23.3%, p = 0.005); tissue perfusion ineffective renal (from non-occurrence to 16.7%, p = 0.024); anxiety (from non-occurrence to 13.3%, p = 0.053). Six domains in the phase pre, and seven in the phase post were identified. There were significant differences in the following domains: comfort (from 48.3% to 73.3%, p = 0.046); nutrition (from 25.8% to 6.6%, p = 0.023) and coping/stress tolerance (from non-occurrence to 13.3%, p = 0.053). These differences indicate that, after the implementation classification, there were greater focus on comfort responses and coping/stress tolerance. The MFA presented different profiles of diagnoses and domains between the phases, indicating that on the phase post there was greater amplitude of the phenomena focused by the nurses. The NANDA-I classification implementation contributes to widen the care focus, increasing the emphasis on less-documented phenomena, as the ones of the coping/stress tolerance domain. The fact that the nurses documented such phenomena as diagnoses increases the responsibility in the selection of proper interventions and in the evaluation of the outcomes. The results to this study are important contributions, which aim at improving the processes of the classification implementation, and at monitoring their effects on the nursing clinical practice.
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Ho, Man-kei Joanne. "Perspectives of Chinese elderly women towards nursing in Hong Kong." Click to view the E-thesis via HKUTO, 2003. http://sunzi.lib.hku.hk/hkuto/record/B31972913.
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Kam, Tat-yan Deyoung. "Workplace violence prevention programme targeting nursing staff in hospital setting." Click to view the E-thesis via HKUTO, 2008. http://sunzi.lib.hku.hk/hkuto/record/B40720792.
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Marks, Steven Adam. "Nurses' attitudes toward computer use for point-of-care charting." CSUSB ScholarWorks, 2001. https://scholarworks.lib.csusb.edu/etd-project/2006.
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van, der Nest Yolinda Louise. "Record review of post-haemodialysis blood results to assess adherence to guidelines for end stage renal disease." Master's thesis, Faculty of Health Sciences, 2021. http://hdl.handle.net/11427/33959.
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Background: End Stage Renal Disease is an irreversible decline in kidney function and fatal in the absence of renal replacement therapy. Resource constraints in the South African public healthcare sector limits patients' access to renal replacement therapy: here 14.8% are on haemodialysis compared to 85.2% in private dialysis units. Quality indicators in internationally accepted guidelines address complications of End Stage Renal Disease for patients on haemodialysis to reduce mortality and morbidity. Monitoring clinical outcomes for patients on haemodialysis is essential for good quality of life. Aim: To design and validate a record review template for monitoring and describing target and actual outcomes for each clinical indicator to assess adherence to established guidelines. Methods Design: Retrospective chart review. Participants: Patient records were accessed from an electronic database in 8 private units between 01 January and 31 December 2018. Data instruments: Data were captured and analysed in SPSS. DAG Stat was used for the Kappa statistic for interrater reliability (test-retest). A P-value of <0.05 was taken as significant. Results: Of the dialysis population (N=412) for the study period n=243 (58.98%) records were excluded. The median age of the convenience sample (169/412, 41.01%) was 60 years (IQR: 21-86), comprising 100/169 (59.17%) males and 69/169 (40.8%) classified as Coloured. Most patients (55/169, 32.54%) had Diabetic Nephropathy. Suboptimal dialysis adequacy (Kt/V levels) was present in 86/133 (64.6%) of the patients, similarly 102/166 (62.5%) for serum phosphate. Arterio-venous fistula or graft is recommended for vascular access for HD and 112/169 (66.27%) patients had either. While all patients should receive erythropoiesis stimulating agents and iron therapy, 110/169 (65.08%) and 104/169 (61.53%) respectively did. For the required phosphate binders and Vitamin D supplements there were recordings for 57/169 (33.72%) and 54/169 (32.72%) patients respectively. Conclusion: Adherence to clinical guidelines for 3/5 quality indicators was considered unsatisfactory which has implications for patients' quality of life.
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Benjamin, Jennifer Claudette. "Incorporating ADA Best Practice Guidelines in Electronic Medical Records to Improve Glycemic Management in Hospitals." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/318.
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Aggressive management of diabetes using American Diabetes Association (ADA) best practice guidelines in hospitalized patients reduces morbidity and mortality. Inpatient electronic medical records systems improve care in chronic diseases by identifying care needs and improving the data available for decision making and disease management. The purpose of this quality improvement project was to evaluate the impact of ADA best practice guidelines of glycemic management once they have been entered into the electronic medical record (EMR) of hospitalized diabetics. Kotter's organizational change process guided the project. The project question investigated whether nurses' use of ADA Best Practice Guidelines incorporated into the EMR improves glycemic management in hospitalized patients. A quality improvement project pretest-posttest design evaluated the intervention to assess whether the program goals were met. A convenience sample of 8 nurses practicing in a subacute health care facility participated in the program with data obtained from a convenience sampling of diabetic patients admitted to the facility (n = 50). A1C, diabetes types, and hypo/hyperglycemic treatment event data were compared 30 days pre- and post-intervention. Outcome data calculated using descriptive statistics revealed improved documentation for A1C results (4% to 96%), the different types of diabetes (from 100% documented as Type 1 to 28 % documented as Type2), and increased corrective measures for abnormal glycemic events (increased 16% to 44%). EMR alerts and reminders provided timely information to health care practitioners, resulting in better management for the diabetic patient, thus affecting social change of diabetes care.
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Clausson, Eva K. "School health nursing : perceiving, recording and improving schoolchildren's health." Doctoral thesis, Högskolan Kristianstad, Sektionen för hälsa och samhälle, 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:hkr:diva-124.
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Aim: The overall aim of this thesis is to explore School health nursing through school nurses’ descriptions of school children’s health and to analyse factors influencing the recording of schoolchildren’s health in the School Health Record (SHR). An additional aim is to evaluate family nursing interventions as a tool for the school nurses in the School Health Service (SHS).Methods: The thesis comprises four papers. A combination of qualitative and quantitative methods was used through individual interviews with a strategic sample of school nurses (n=12) (PI), a national survey to a representative sample of school nurses (n=129) (PII, III) and the implementation of family nursing models developed in Canada with girls in their early adolescence with recurrent health complaints and their families (n=4) in co-operation with their school nurses (n=2) (PIV). The Strengths and Difficulties Questionnaire (SDQ) was used as pre and post test. Evaluation interviews were conducted with the families and the nurses separately. Qualitative content analyses were used to analyze the interview text with the school nurses and the families. Manifest content analysis was used to analyze the free text answers of the survey and the evaluation interview with the school nurses. Descriptive statistical analyses were used to describe demographic data in all four papers. The SDQ was hand-scored statistically.Findings: The findings showed that nurses judged the schoolchildren’s mental health as deteriorated, especially in socially disadvantaged areas and more generally among girls expressed as psychosomatic symptoms. Individual factors related to lifestyle affected the schoolchildren’s physical health, and the mental health was, to a large extent, affected by the school environment and family relations. The latter seemed to be the most important factor affecting schoolchildren’s mental health. The basis for the school nurses judgement of the physical health was health check-ups and the health dialogues. Spontaneous visits were more commonly used to judge the mental health. Recording schoolchildren’s mental health was a challenge for school nurses. Difficulties were related to ethical considerations, tradition, lack of time and the improper structure of the SHR. Fears of marking the schoolchild for life related to the schoolchild itself, the parents or to other authorities/successive caregivers were brought up as hinders for recording mental and social health. Family sessions may be useful within the profession when handling recurrent health complaints among adolescence girls. The girls and their families experienced relief, they felt confirmed and that their feelings and reactions were normal in that situation. The families became aware of their own strengths and possibilities and this was supported by the SDQ which showed an increased well-being. The school nurses valued this way of working and meant that the sessions seemed to start a changing process within the families.Conclusions: The results indicate that school nurses have a deep knowledge about schoolchildren’s health which is not used to its full potential in a public health perspective. However, the experienced difficulties recording schoolchildren’s mental health seem obvious, which would demand developing the SHR for the needs of today. Family sessions in SHS with the school nurse as a collaborator with the family seemed useful and may be transferable to other health problems expressed by the schoolchildren. Bronfenbrenner’s ecological systems theory and other models for health determinants are used to illustrate the school nurse as a mediator working on the bridge over different health streams with schoolchildren’s health on an individual and a population level.Syfte: Avhandlingens övergripande syfte är att undersöka skolsköterskors uppfattning om skolbarns hälsa och att analysera faktorer som påverkar dokumentation av skolbarns hälsa i skolhälsovårdsjournalen. Ett ytterligare syfte är att utvärdera modeller för familjeinterventioner som redskap för skolsköterskor i skolhälsovård.Metoder: Avhandlingen består av fyra delarbeten. En kombination av kvalitativa och kvantitativa metoder användes. I delarbete I genomfördes intervjuer med ett strategiskt urval av skolsköterskor (n=12). Intervjuerna analyserades med kvalitativ innehållsanalys. I delarbeten II och III distribuerades en nationell enkät till ett representativt urval av Sveriges skolsköterskor (n=129). Manifest innehållsanalys användes vid analys av de öppna frågorna. I delarbete IV genomfördes en interventionsstudie med familjesamtal, inspirerad av modeller för familjefokuserad omvårdnad utvecklade i Kanada. Skolflickor i tidig adolescens med återkommande subjektiva hälsoproblem (n=4) och deras föräldrar i samarbete med deras verksamma skolsköterskor (n=2) ingick i studien. Separata utvärderingsintervjuer genomfördes med familjer och skolsköterskor. Intervjuerna analyserades med kvalitativ och manifest innehållsanalys respektive. The Strengths and Difficulties Questionnaire (SDQ) användes som före/efter test vid interventionen och resultatet bearbetades statistiskt manuellt. Deskriptiv statistik användes för analys av demografisk data i samtliga delarbeten.Resultat: Resultatet visade att skolsköterskorna bedömde skolbarnens mentala hälsa som försämrad särskilt bland flickor och i socioekonomiskt utsatta områden. Individuella livsstilsfaktorer påverkade skolbarnens fysiska hälsa och den mentala hälsan var i stor utsträckning påverkad av skolmiljö och familjerelationer. Det sistnämnda verkade vara den mest betydelsefulla påverkansfaktorn för skolbarnens mentala hälsa. Bedömningen av den fysiska hälsan baserades på hälsokontroller och hälsosamtal medan spontana besök var vanligare för bedömning av den mentala hälsan. Dokumentation av mentala hälsa var en utmaning för skolsköterskorna. Svårigheterna kunde relateras till etiska överväganden, tradition och tidsbrist samt till skolhälsovårdsjournalens struktur som inte ansågs uppfylla dagens krav. Skolsköterskorna uttryckte en rädsla för att journalanteckningarna skulle märka skolbarnet för livet. Framtida tolkningar relaterade till skolbarnet själv, föräldrar eller andra/påföljande vårdgivare uttrycktes som hinder för att dokumentera mental och social hälsa. Familjesamtal visade sig vara användbara i skolhälsovården. De medverkande flickorna och deras familjer kände sig bekräftade i att deras känslor och reaktioner var normala. De sade sig bli medvetna om egna styrkor och möjligheter vilket styrktes av SDQ som visade ett ökat välbefinnande efter sammankomsterna, både hos skolbarnen och hos föräldrarna. Skolsköterskorna var positiva till att arbeta med familjesamtal och upplevde sig mer som samverkanspartner än som expert. Samtalen ledde till att en förändringsprocess startade i familjerna enligt skolsköterskorna.Slutsatser: Resultatet indikerar att skolsköterskor har en djup kunskap om skolbarns hälsa som sannolikt kunde tas tillvara på ett bättre sätt ur ett folkhälsoperspektiv på såväl nationell som lokal nivå. Behovet av att utveckla skolhälsovårdsjournalen efter dagens behov och fördjupad kunskap om de upplevda svårigheterna att dokumentera skolbarns mentala hälsa är uppenbar. Familjesamtal, där skolsköterskan intar en roll som samverkanspartner, visade sig användbara och kan sannolikt överföras till andra hälsoproblem bland skolbarn. Bronfenbrenners utvecklingsekologiska systemteori och andra modeller för hälsodeterminanter används för att illustrera skolsköterskans arbete med skolbarns hälsa på såväl en individuell nivå som folkhälsonivå.
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Gregório, Tânia Raquel Tavares. "Um olhar sobre Enfermagem Perioperatória: importância da visita pré-operatória de enfermagem: aspetos sobre registos de enfermagem, um critério de qualidade." Master's thesis, Instituto Politécnico de Setúbal. Escola Superior de Saúde, 2014. http://hdl.handle.net/10400.26/7944.
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Relatório de estágio do Curso de Mestrado em Enfermagem PerioperatóriaEste Relatório de Estágio pretende apresentar o percurso de aquisição e desenvolvimento de competências em ligação ao projeto realizado e contexto de estágio desenvolvido, no âmbito do Mestrado de Enfermagem Perioperatória. O período referente ao presente relatório teve início em Maio de 2011 e terminou em Agosto de 2013. Durante este tempo decorreram dois estágios em contexto perioperatório. O primeiro foi realizado no âmbito da 1ª Pós-Graduação em Enfermagem Perioperatória e o segundo durante o Mestrado de Enfermagem Perioperatória. No estágio houve oportunidade para realizar um projeto intitulado: Revisão do Procedimento da Visita Pré-Operatória de Enfermagem - “Importância da Visita Pré-Operatória de Enfermagem: Aspetos sobre registos de enfermagem, um critério de qualidade”, objetivando contribuir para a melhoria da qualidade dos cuidados de enfermagem prestados aos clientes que vão ser submetidos a cirurgia no Bloco Operatório de um Hospital da Administração Regional de Saúde de Lisboa e Vale do Tejo. Para a realização do projeto foi utilizada a metodologia de projeto, tendo sido identificado como problema a desatualização do procedimento da Visita Pré-Operatória de Enfermagem. Para suportar a pertinência do projeto, foi realizada uma revisão sistemática da literatura, que destaca a importância da visita pré-operatória de enfermagem. Com a execução deste projeto, construíram-se alguns instrumentos, nomeadamente: a folha de registos da visita pré-operatória anestésico-cirúrgica de enfermagem, que visou identificar a importância da visita pré-operatória de enfermagem, e que veio facilitar a prática de enfermagem perioperatória; e um questionário para avaliar essa prática que foi aplicado à totalidade dos enfermeiros do serviço. Concluiu-se, que a Visita Pré-Anestésico-Cirúrgica de Enfermagem é considerada muito importante (86%) pelos enfermeiros do bloco operatório em estudo. Dos inquiridos, 13% referiu que existem falhas na folha de registos da Visita Pré Anestésico Cirúrgica de enfermagem e 18% dos enfermeiros, considera que a folha de registos da Visita Pré Anestésico Cirúrgica de enfermagem, não comtempla informação suficiente para uma adequada prestação de cuidados ao cliente. Também foi possível detetar que cerca de 41%, não descreve qual o diagnóstico identificado no campo referente às “Necessidades ou potenciais necessidades identificada/Diagnósticos levantados”, sobretudo porque apresentam dificuldade na descrição de diagnósticos na linguagem CIPE. No questionário ainda se constatou que 27% dos enfermeiros, não identificava as “Necessidades ou potenciais necessidades identificadas” dos clientes. A emergência da melhoria da qualidade em conjunto com a informação obtida no questionário, levou-nos a considerar a realização de uma revisão/atualização da folha de registos da Visita Pré Anestésico Cirúrgica de Enfermagem.
This Internship Report aims to present the route of acquisition and skills development in connection to the project undertaken and the context of developed stage, under the Master of Perioperative Nursing. The period relating to this report began in May 2011 and ended in August 2013 during this time took place in two stages perioperative period. The first was carried out within the 1st Graduate in Perioperative Nursing and the second during the Master of Perioperative Nursing. On stage there was opportunity for a project entitled: Review of Preoperative Visit Nursing Procedure - "Importance of Preoperative Visit Nursing: Aspects of nursing records, a criterion of quality", aiming to contribute to improving the quality nursing care provided to clients who will be undergoing surgery in the Operating Room of a Hospital Regional Health Administration of Lisbon and Vale doTejo. To carry out the project design methodology, has been identified as a problem to downgrade the procedure Visit Preoperative Nursing was used. To support the relevance of the project, a systematic review of the literature, which highlights the importance of preoperative nursing visit was made. With the execution of this project, built up some instruments, namely: a sheet of records of anesthetic and surgical preoperative visit nursing, which aimed to identify the importance of preoperative nursing visit, and which facilitates the practice of nursing perioperative; and a questionnaire to assess this practice which was applied to all the nurses of the service. It was concluded that the Visit Pre-Anesthetic-Surgical Nursing is considered very important (86%) by nurses in the operating room study. Of the respondents, 13% reported that there are flaws in the sheet records Visit Pre Anesthetic Surgical nursing and 18% of nurses, believes that the record sheet Visit Pre Anesthetic Surgical Nursing, contemplates not enough information for proper care customer. It was also possible to detect a significantly significant number of nurses, namely 41%, does not describe what the diagnosis identified in the field referring to the needs or potential needs identified / raised Diagnostics", mainly because they have difficulty in describing diagnoses in CIPE language. The questionnaire was also found that 27% of nurses did not “identify the needs or potential needs identified” customer. The emergence of quality improvement together with the information obtained in the questionnaire, led us to consider conducting a review / update of sheet records Visit Pre Anesthetic Surgical Nursing.
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Obioma, Chidiadi. "Improving the Quality of Nursing Documentation in Home Health Care Setting." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/3500.
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Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the quality of documentation of patient care in nurses' notes in a home health agency in central Texas. A retrospective audit of quality of nursing documentation using the Nurse and Midwifery Content Audit Tool (NMCAT) was done. A pre- and posttest design was used. A convenience sample of de-identified nurses' notes (80 pre- and 80 post) was selected from active patient records in the agency (n = 160). Descriptive and inferential statistics from the project showed that there was improved quality for the 15 criteria representing quality nursing documentation. After the educational intervention, documentation of patient's status if changed or unchanged improved to 80%, and patient's response to treatment improved (57% to 85%), entries were written as incidents occurred improved (53% to 64%). The nurse refers to the patient by name improved (0% to 66%). These findings were an indication of practice change, validating the need for periodic audits of nurses' notes in the agency in order to demonstrate compliance with quality standards. Based on the project findings, a retraining program is recommended to improve structured nursing documentation in a home health agency. This project is likely to contribute to social change as it enhanced the information communicated to other health care providers, coordination of care, and patient outcomes.
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Drew, Denise. "The culture of community nursing : an ethnographic study of handover reports." Thesis, Swansea University, 2008. https://cronfa.swan.ac.uk/Record/cronfa42783.
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This study explores the culture of community nurses exhibited during the time spent together in handover reports. As community nurses spend much of their shifts working alone in patients' houses, this is the time to meet up in clinics and health centres to share information about patient care. Culture is observed through group interactions, behaviour, language, ritual and the use of artefacts and so this handover time provides the opportunity to explore these matters. The research question is: what cultural behaviour, cultural knowledge and cultural artefacts are exemplified during community nurses' handover reports? Using an ethnographic approach, data collection was carried out using participant observation and semi-structured interviews. Two teams of nurses from one Primary Care Trust in the West Midlands participated in this study. The resulting data was analysed using James Spradley's (1979) thematic cultural analysis and the findings are presented in four sections. Findings include: sharing information and planning ahead, helping across teams and busyness, being in the team and how others see us. Issues of community nurses invisibility and the articulation of expertise are presented. Some of the findings were congruent with earlier studies (largely set in hospital or nursing homes) including teaching and learning and support for staff. In addition, this study adds the following considerations to the body of knowledge relating to handover reports. Firstly, the importance of protecting reporting time for community nurses is suggested. In the current social and financial climate it is essential to make the case for continuity of care to be safeguarded. Secondly, the importance of professional identity for community nurses is stressed. The reporting time serves to enhance group identity, reduce anxieties and relieve isolation. Finally, report time crucially encourages the articulation of expertise between community nurses at a time when they are feeling professionally devalued.