Journal articles: 'Nursing and nursing records'

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Hillery, S. A. "Nursing records prove invaluable." Nursing Standard 4, no. 50 (September 5, 1990): 41–42. http://dx.doi.org/10.7748/ns.4.50.41.s45.

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AHN, HEE-JUNG, and HYEOUN-AE PARK. "Adverse-Drug-Event Surveillance Using Narrative Nursing Records in Electronic Nursing Records." CIN: Computers, Informatics, Nursing 31, no. 1 (January 2013): 45–51. http://dx.doi.org/10.1097/nxn.0b013e318270106e.

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Núñez Zarazú, Llermé, Bibiana León Huerta, and Olga Giovanna Valderrama-Ríos. "Comparison of traditional and automated nursing records in the medicine services of the Callejón de Huaylas hospitals - Peru [Comparación de los registros de enfermería tradicionales y automatizados en los servicios de medicina de los hospitales del Callejón de Huaylas – Perú]." Journal of Global Health and Medicine 5, no. 1 (March 3, 2021): 1. http://dx.doi.org/10.32829/ghmj.v5i1.217.

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The objective of this study was to compare the quality of traditional and automated nursing records in the medical services of four hospitals in Callejón de Huaylas - Peru. Investigation of quantitative approach quasi experimental. The population consisted of 32,940 nursing records from the medical records, and the sample consisted of 816 records, selected by stratified probability sampling. The instruments used were; Quality inventory of the nursing record and the software called the Automated Nursing Record System (SIARE) version 1.0. The results show that the difference in quality of the traditional and automated nursing records, with the student's t test obtained a mean of 7.284, a SD of 1.172, a t value = 29.815, with d.f. 22 and a p value = 0.000, resulting in significant differences between the quality scores of the traditional and automated nursing records of the medicine services of the hospitals of the Callejón de Huaylas. It is concluded that the quality (structure, continuity of care and patient safety) of the automated records is high in comparison with traditional nursing records.

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Christensen, Martin. "Men in nursing: The early years." Journal of Nursing Education and Practice 7, no. 5 (January 3, 2017): 94. http://dx.doi.org/10.5430/jnep.v7n5p94.

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Objective: Nursing is as old as mankind and the nature of what it means to be a man in nursing has a wide and varied history. Men have been at the forefront of nursing practice from before the birth of Christ – the first record of male nursing originates from ancient India. Slowly over time the image of the male nurse has given way to the dominance of women largely thanks to Florence Nightingale. The aim of this paper is to discuss the contribution men have made to the profession of nursing through the early years of nursing’s history in particular from 250BC to the early 1900’s.Methods and result: Design: A historical review. Data Sources: The search strategy included research studies both qualitatively and quantitatively, as well as anecdotal and discursive evidence from 1900-2015. Implications for Nursing: The predominance of the history of has always had a focus on the female perspective. Men have had played a significant part in the development of that history. Acknowledging the role men have contributed in developing and promoting nursing practice is equally as valid and as such should be recognised accordingly.Conclusions: Male nursing has had a varied history from the first recoded nursing school in 256BC to its slow eventual slow demise from the 1840’s. Records reveal the work of the male nurse was seen predominately within secular institutions and personified aspects of care that focused totally on patient wellbeing both physically and spiritually.

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Roberts, Carol, and Rita Smith. "Improving nursing records with audit." Nursing Standard 7, no. 51 (September 8, 1993): 37–39. http://dx.doi.org/10.7748/ns.7.51.37.s47.

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Wright, Stephen, and Nasrin Khadim. "Patients’ access to nursing records." Nursing Standard 5, no. 11 (December 5, 1990): 22–24. http://dx.doi.org/10.7748/ns.5.11.22.s44.

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Nomura, Aline Tsuma Gaedke, Lisiane Pruinelli, Marcos Barragan da Silva, Amália de Fátima Lucena, and Miriam de Abreu Almeida. "Quality of Electronic Nursing Records." CIN: Computers, Informatics, Nursing 36, no. 3 (March 2018): 127–32. http://dx.doi.org/10.1097/cin.0000000000000390.

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Nordström, Gun, and Ann Gardulf. "Nursing Documentation in Patient Records." Scandinavian Journal of Caring Sciences 10, no. 1 (March 1996): 27–33. http://dx.doi.org/10.1111/j.1471-6712.1996.tb00306.x.

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Ehrenberg, Anna, and Margareta Ehnfors. "Patient Records in Nursing Homes." Scandinavian Journal of Caring Sciences 13, no. 2 (June 1999): 72–82. http://dx.doi.org/10.1111/j.1471-6712.1999.tb00519.x.

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Pickersgill, Frances. "Nursing records: collecting relevant information." Primary Health Care 7, no. 4 (May 1997): 16. http://dx.doi.org/10.7748/phc.7.4.16.s16.

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Carpenter, G., and D. Sturdy. "Standardised Nursing Admission Assessment and the Completeness of Nursing Records." Age and Ageing 26, suppl 1 (January 1, 1997): P34. http://dx.doi.org/10.1093/ageing/26.suppl_1.p34-b.

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Jones, Dorothy, Margaret Lunney, Gail Keenan, and Sue Moorhead. "Standardized Nursing Languages Essential for the Nursing Workforce." Annual Review of Nursing Research 28, no. 1 (December 2010): 253–94. http://dx.doi.org/10.1891/0739-6686.28.253.

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The evolution of standardized nursing languages (SNLs) has been occurring for more than four decades. The importance of this work continues to be acknowledged as an effective strategy to delineate professional nursing practice. In today's health care environment, the demand to deliver cost-effective, safe, quality patient care is an essential mandate embedded in all health reform policies. Communicating the contributions of professional nursing practice to other nurses, health providers, and other members of the health care team requires the articulation of nursing's focus of concern and responses to these concerns to improve patient outcomes. The visibility of the electronic health record (EHR) in practice settings has accelerated the need for nursing to communicate its practice within the structure of the electronic format. The integration of SNLs into the patient record offers nurses an opportunity to describe the focus of their practice through the identification of nursing diagnosis, interventions and outcomes (IOM, 2010). Continued development, testing, and refinement of SNLs offers nursing an accurate and reliable way to use data elements across populations and settings to communicate nursing practice, enable nursing administrators and leaders in health care to delineate needed resources, cost out nursing care with greater precision, and design new models of care that reflect nursepatient ratios and patient acuity that are data driven (Pesut & Herman, 1998). The continued use of nursing languages and acceleration of nursing research using this data can provide the needed evidence to help link nursing knowledge to evidence-driven, cost-effective, quality outcomes that more accurately reflect nursing's impact on patient care as well as the health care system of which they are a part. The evaluation of research to support the development, use, and continued refinement of nursing language is critical to research and the transformation of patient care by nurses on a global level.

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Anderson, Barbara. "Clinical Records in Nursing Homes — What are They and Why Do we Need Them?" Australian Medical Record Journal 19, no. 3 (September 1989): 105–8. http://dx.doi.org/10.1177/183335838901900304.

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The importance of clinical records to holistic client centre care is highlighted by the outcome standards which nursing homes in Australia now have to meet. The clinical record system therefore must be organised in such a way as to provide evidence that a nursing home is meeting the desired outcome standards. In this paper the author reviews some of the records problems typically encountered by nursing homes and offers potential solutions. The point is made that any nursing home with poor clinical records can expect to have difficulty meeting the outcome standards. (AMRJ, 19(3), 105–108).

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Wu, Mi-Zhi, Hong-Ying Pan, and Zhen Wang. "Nursing decision support system: application in electronic health records." Frontiers of Nursing 7, no. 3 (October 2, 2020): 185–90. http://dx.doi.org/10.2478/fon-2020-0027.

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AbstractThe clinical decision support system makes electronic health records (EHRs) structured, intelligent, and knowledgeable. The nursing decision support system (NDSS) is based on clinical nursing guidelines and nursing process to provide intelligent suggestions and reminders. The impact on nurses’ work is mainly in shortening the recording time, improving the quality of nursing diagnosis, reducing the incidence of nursing risk events, and so on. However, there is no authoritative standard for the NDSS at home and abroad. This review introduces development and challenges of EHRs and recommends the application of the NDSS in EHRs, namely the nursing assessment decision support system, the nursing diagnostic decision support system, and the nursing care planning decision support system (including nursing intervene), hoping to provide a new thought and method to structure impeccable EHRs.

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Ehrenberg, Anna, and Margareta Ehnfors. "Patient Problems, Needs, and Nursing Diagnoses in Swedish Nursing Home Records." International Journal of Nursing Terminologies and Classifications 10, no. 2 (April 1999): 65–76. http://dx.doi.org/10.1111/j.1744-618x.1999.tb00028.x.

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Liljamo, Pia, Ulla-Mari Kinnunen, and Kaija Saranto. "Assessing the relation of the coded nursing care and nursing intensity data: Towards the exploitation of clinical data for administrative use and the design of nursing workload." Health Informatics Journal 26, no. 1 (December 5, 2018): 114–28. http://dx.doi.org/10.1177/1460458218813613.

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Patient-care data from the electronic health record systems are increasingly in demand for re-use in administration and resource planning. Nursing documentation with coded concepts is expected to produce more reliable data, fulfilling better requirements for re-use. The aim was to ascertain what kind of relation exist between coded nursing diagnoses, nursing interventions, and nursing intensity and to discuss the possibilities for re-using nursing data for workload design. We analysed the retrospective nursing records of 794 patients documented by the Finnish Care Classification and nursing intensity data assessed by the Oulu Patient Classification over a 15-day period in nine inpatient units at a university hospital. Using the generalised linear mixed model, the clear relationship between the number of coded nursing notes and nursing intensity levels were ascertained. The number of coded nursing notes increases when the nursing intensity increases. The outcomes construct a good basis for continuing elaboration of electronic health record data re-use.

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Hardiker, N., J. Kirby, R. Tallis, M. Gonsalkarale, and H. A. Heathfield. "The PEN & PAD Medical Record Model: Development of a Nursing Record for Hospital-based Care of the Elderly." Methods of Information in Medicine 33, no. 05 (1994): 464–72. http://dx.doi.org/10.1055/s-0038-1635061.

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Abstract:The PEN & PAD Medical Record model describes a framework for an information model, designed to meet the requirements of an electronic medical record. This model has been successfully tested in a computer-based record system for General Practitioners as part of the PEN & PAD (GP) Project.Experiences of using the model for developing computer-based nursing records are reported. Results show that there are some problems with directly applying the model to the nursing domain. Whilst the main purpose of the nursing record is to document and communicate a patient’s care, it has several other, possibly incompatible, roles. Furthermore, the structure and content of the information contained within the nursing record is heavily influenced by the need for the nursing profession to visibly demonstrate the philosophical frameworks underlying their work. By providing new insights into the professional background of nursing records, this work has highlighted the need for nurses to clarify and make explicit their uses of information, and also provided them with some tools to assist in this task.

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Zimmerman, Sheryl, Lauren W. Cohen, Kezia Scales, David Reed, Christina Horsford, David J. Weber, and Philip D. Sloane. "Pneumonia Identification Using Nursing Home Records." Research in Gerontological Nursing 9, no. 3 (December 29, 2015): 109–14. http://dx.doi.org/10.3928/19404921-20151218-01.

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Klein, Aline Staub, Julia Valeria Oliveira Vargas Bitencourt, Daiane Dal Pai, and Wiliam Wegner. "Nursing records in the perioperative period." Revista de Enfermagem UFPE on line 5, no. 5 (June 24, 2011): 1096. http://dx.doi.org/10.5205/reuol.1302-9310-2-le.0505201103.

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ABSTRACT Objective: to evaluate the records of nursing in the perioperative period from a hospital in Porto Alegre, Rio Grande do Sul. Method: a quantitative approach, with a descriptive, conducted with 110 records from January and February 2010, through a form with closed questions. Approved by the Ethics Committee of the Methodist University IPA (346/2009) and the Institution search (357/CEM/09). Results: 65,4% of records had no nursing records. Only 7,3% of the medical records were analyzed on the history of the patient's health and on their physical assessment. At surgery, the patient's position was the most frequent item of complete records (13,6%), whereas postoperatively were vital signs (57,3%). Conclusion: there is a shortage of perioperative nursing records, which compromises the nursing process. It is suggested that the institutionalization of a single instrument that enables systematic records of perioperative, thereby stimulating a flow of information about the surgical procedure - an event vital to human life. Descriptors: perioperative care; operating room nursing; nursing records; postoperatively. RESUMO Objetivo: avaliar os registros de enfermagem no período perioperatório de um Hospital de Porto Alegre, Rio Grande do Sul. Método: trata-se de estudo quantitativo, com abordagem descritiva, realizado com 110 prontuários no período de Janeiro e Fevereiro de 2010, por meio de um formulário com questões fechadas. Aprovado pelo Comitê de Ética do Centro Universitário Metodista IPA (346/2009) e da Instituição pesquisada (357/CEM/09). Resultados: 65,4% dos prontuários não apresentaram registros de enfermagem. Apenas 7,3% dos prontuários analisados apresentaram registros sobre a história de saúde do paciente e sobre a sua avaliação física. No transoperatório, o posicionamento do paciente foi o item com maior frequência de registros completos (13,6%), enquanto que no pós-operatório foram os sinais vitais (57,3%). Conclusão: há escassez de registros de enfermagem no perioperatório, o que compromete o processo de enfermagem. Sugere-se a institucionalização de um instrumento único e sistematizado para os registros do perioperatório, estimulando assim um fluxo de informações sobre o procedimento cirúrgico – evento vital para a vida humana. Descritores: assistência perioperatória; enfermagem centro cirúrgico; registros de enfermagem; pós-operatório. RESUMEN Objetivo: evaluar los registros de enfermería en el perioperatorio de un hospital de Porto Alegre, Rio Grande do Suly. Métodos: un enfoque cuantitativo, con un estudio descriptivo, realizado con 110 registros de enero y febrero de 2010, a través de un formulario con preguntas cerradas. Aprobado por el Comité de Ética de la API de la Universidad Metodista (346/2009) y la búsqueda de la Institución (357/CEM/09). Resultados: el 65,4% de los registros no tenían registros de enfermería. Sólo el 7,3% de las historias clínicas fueron analizadas en la historia de la salud del paciente y de su evaluación física. En la cirugía, la posición del paciente fue el tema más frecuente de registros completos (13,6%), mientras que después de la operación fueron los signos vitales (57,3%). Conclusión: hay una escasez de registros de enfermería perioperatoria, lo que compromete el proceso de enfermería. Se sugiere que la institucionalización de un solo instrumento que permite un registro sistemático de perioperatorio, estimulando así un flujo de información sobre el procedimiento quirúrgico - un acontecimiento vital para la vida humana. Descriptores: cuidados perioperatorios; la enfermería de quirófano; enfermería registros; después de la operación.

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Ehrenberg, Anna, Margareta Ehnfors, and Bjorn Smedby. "Auditing nursing content in patient records." Scandinavian Journal of Caring Sciences 15, no. 2 (June 22, 2001): 133–41. http://dx.doi.org/10.1046/j.1471-6712.2001.00011.x.

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MOODY, LINDA E., ELAINE SLOCUMB, BRUCE BERG, and DONNA JACKSON. "Electronic Health Records Documentation in Nursing." CIN: Computers, Informatics, Nursing 22, no. 6 (November 2004): 337–44. http://dx.doi.org/10.1097/00024665-200411000-00009.

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Fisette, K., J. P. Laforest, S. Robert, and C. Farmer. "Use of recorded nursing grunts during lactation in two breeds of sows. I. Effects on nursing behaviour and litter performance." Canadian Journal of Animal Science 84, no. 4 (December 1, 2004): 573–79. http://dx.doi.org/10.4141/a03-124.

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The impact of exposing lactating sows and their litters to recorded sow nursing grunts played at different intervals during lactation was studied. Yorkshire × Landrace (YL) and 25% Meishan (MH) primiparous sows were divided into three groups (n = 14): (1) no playback, (2) playbacks at 35-min intervals (GR35), and (3) playbacks at 40-min intervals (GR40). Recordings were played from day 110 of gestation to day 27 of lactation. Nursing behaviours, incidence of nursings without milk ejection (NPN), nursing interval and proportion of nursings induced by playbacks were measured on days 6, 18 and 26 of lactation. Litter size was standardized to 10 ± 1 piglets within 48 h of birth and piglets were weighed weekly. Mean nursing intervals, excluding NPN, were shorter for MH than for YL sows (P < 0.001). The increase in mean nursing interval between days 6 and 18 was greater in GR40 than in GR35 or controls (P < 0.01) and, when excluding NPN, the mean nursing interval decreased in GR35 on day 18 (P = 0.01). The occurrence of NPN decreased as lactation advanced (P < 0.001) and was lower for MH than YL sows on day 26 (P < 0.001). Between days 6 and 18, the proportion of nursings initiated by playbacks increased (P < 0.05) and the duration of milk ejection decreased (P < 0.001). In MH sows, controls had longer milk ejections than GR35 (P < 0.05) whereas, in YL sows, controls had shorter milk ejections than GR40 (P < 0.05) and GR35 (P = 0.06). Piglet growth was not affected by treatments or breed (P > 0.1). In conclusion, exposing sows and their litters to recorded sow nursing grunts played at 35-min intervals reduced nursing intervals on day 18 of lactation only, without affecting piglet performance. Key words: Auditory stimulus, behaviour, lactation, litter performance, Meishan, sows

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Kim, Yun Jeong, and Hyeoun Ae Park. "Analysis of Nursing Records of Cardiac Surgery Patients Based on Nursing Process Focusing on Nursing Outcome." Journal of Korean Society of Medical Informatics 11, no. 1 (2005): 45. http://dx.doi.org/10.4258/jksmi.2005.11.1.45.

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Baik, Seung Yeon, Eunhee Cho, Young Ah Kim, and Mona Choi. "Emergency Department Nursing Activities: Retrospective Study on Data from Electronic Nursing Records." Korean Journal of Adult Nursing 31, no. 5 (2019): 496. http://dx.doi.org/10.7475/kjan.2019.31.5.496.

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Lee, Insil, and Hyeoun-Ae Park. "Comparison of Nursing Records of Open Heart Surgery Patients before and after Implementation of Electronic Nursing Record." Journal of Korean Society of Medical Informatics 15, no. 1 (2009): 83. http://dx.doi.org/10.4258/jksmi.2009.15.1.83.

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Wilburn, Amber. "Nursing Informatics: Ethical Considerations for Adopting Electronic Records." NASN School Nurse 33, no. 3 (May 31, 2017): 150–53. http://dx.doi.org/10.1177/1942602x17712020.

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School districts are commonly adopting electronic storage systems, including electronic health records. Included in this adoption is a move toward cloud-based record storage systems to handle the increasing volumes of data. Deciding which system to adopt is especially difficult in times of tightening school district budgets. While there are several options to consider, including the outright purchase of a proprietary system or choosing one of a relatively new group of free programs, lead nurses must work to ensure that student information is protected and that any chosen system complies with privacy laws. This article provides a case study and presents legal and ethical considerations related to maintaining the privacy of health records in the school setting.

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Da Silva, Thaynan Gonçalves, Regina Maria Dos Santos, Laís De Miranda Costa Crispim, and Lenira Maria Wanderley Santos De Almeida. "CONTEÚDO DOS REGISTROS DE ENFERMAGEM EM HOSPITAIS: CONTRIBUIÇÕES PARA O DESENVOLVIMENTO DO PROCESSO DE ENFERMAGEM." Enfermagem em Foco 7, no. 1 (April 2, 2016): 24–27. http://dx.doi.org/10.21675/2357-707x.2016.v7.n1.679.

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Objetivos: o estudo buscou analisar o conteúdo dos registros de enfermagem nos prontuários dos pacientes internados em dois hospitais de Maceió-AL e investigar quais as contribuições do conteúdo dos registros para a prática assistencial baseada no Processo de Enfermagem. Metodologia: trata-se de uma pesquisa com abordagem quantitativa. Foram analisados 843 registros, no período de maio/dezembro de 2012. Resultados: os dados evidenciaram que o conteúdo dos registros é deficiente, não retrata a realidade do paciente nem tampouco a assistência de enfermagem prestada. Conclusão: os registros realizados pela equipe de enfermagem não contribuem para o desenvolvimento do processo de enfermagem desses pacientes.Descritores: Enfermagem, Registros de Enfermagem, Cuidados de Enfermagem.The content of nursing records in hospitals : contributions to the development of the nursing processObjectives: this study aimed to analyze the content of nursing’s registries us patient’s records hospitalized in two hospitals from Maceió- Al and investigate what the contributions from registrie’s content to care practice based in the nursing’s process. Methodology: this is a quantitative study. Were analyzed 843 registries. Results: the data showed that registrie’s content is deficient, do not show the patient’s reality, nor the nursing’s care. Conclusion: the registries made by nursing’s team do not content to development of nursing’s process of these patients.Descriptors: Nursing, Nursing Care, Nursing Records.El contenido de los registros de enfermería en los hospitales : contribuciones al desarrollo del proceso de enfermeríaObjetivos: el estudio buscó analizar el contenido de los registros de enfermería en los registros de los pacientes ingresados en dos hospitales de Maceió-AL e investigar cuales las contribuciones de los contenidos de los registros para la práctica asistencial basada en el proceso de enfermería. Metodología: tratase de un estudio con un enfoque cuantitativo. Se analizaron 843, en el período de la coleta de daos. Resultados: los dados mostraron que el contenido de los registros es deficiente, no retrata la realidad del paciente, ni tan poco la asistencia de enfermería. Conclusión: los registros realizados por el personal de enfermería no contribuyen al desarrollo del proceso de enfermería de eses pacientes.Descriptores: Enfermería, Registros de Enfermería, Atención de Enfermería.

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Willems, E., V. Van de Velde, K. Goethals, Y. Benoit, and G. Laureys. "Search for a good fit between nursing practice and electronic nursing records: benefits and limitations of nursing records on a pediatric hemato-oncology ward." European Journal of Oncology Nursing 17, no. 6 (December 2013): 898–99. http://dx.doi.org/10.1016/j.ejon.2013.09.030.

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Roberts, Darryl W. "Representing nursing knowledge in electronic health records." Nursing Management (Springhouse) 43, no. 8 (August 2012): 12–14. http://dx.doi.org/10.1097/01.numa.0000416411.06474.2f.

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Ehnfors, Margareta, and Björn Smedby. "Nursing Care as Documented in Patient Records." Scandinavian Journal of Caring Sciences 7, no. 4 (December 1993): 209–20. http://dx.doi.org/10.1111/j.1471-6712.1993.tb00206.x.

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Ehnfors, Margareta, Ingrid Thorell-Ekstrand, and Anna Ehrenberg. "Towards Basic Nursing Information in Patient Records." Nordic Journal of Nursing Research 11, no. 3-4 (September 1991): 12–31. http://dx.doi.org/10.1177/010740839101100303.

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Stonham, Gill, Barbara Heyes, Anne Owen, and Erin Povey. "Measuring the nursing contribution using electronic records." Nursing Management 19, no. 8 (November 28, 2012): 28–32. http://dx.doi.org/10.7748/nm2012.12.19.8.28.c9447.

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Inoue, Sozo, Paula Lago, Tahera Hossain, Tittaya Mairittha, and Nattaya Mairittha. "Integrating Activity Recognition and Nursing Care Records." Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies 3, no. 3 (September 9, 2019): 1–24. http://dx.doi.org/10.1145/3351244.

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Liang, Hongliu, Jing Huang, Jijia Tong, and Jinyue Wang. "Application of Rapid Rehabilitation Nursing in Thoracic Surgery Nursing." Journal of Healthcare Engineering 2021 (September 2, 2021): 1–9. http://dx.doi.org/10.1155/2021/6351170.

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To study the application effect of rapid rehabilitation nursing intervention in thoracic surgery nursing, this paper researches controlled trials. First, this paper sets up a control group and a test group. The control group uses traditional nursing methods for thoracic surgical nursing intervention, and the test group adds rapid rehabilitation nursing intervention based on traditional nursing intervention. In addition, the operation and rehabilitation conditions of the control group and the test group are the same. Moreover, this paper records rehabilitation information in real time, performs data processing through statistical methods, and conducts follow-up surveys on the rehabilitation process of patients. In addition, this paper compares nursing effects through data comparison and histogram comparison. From the research results, various parameters of the patient’s recovery process and the user satisfaction of the rapid rehabilitation can be seen. Furthermore, nursing is higher than those of the control group, which shows that the rapid rehabilitation nursing method can positively affect the nursing of thoracic surgery.

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Kim, Yun Jeong, and Hyeoun-Ae Park. "Analysis of nursing records of cardiac-surgery patients based on the nursing process and focusing on nursing outcomes." International Journal of Medical Informatics 74, no. 11-12 (December 2005): 952–59. http://dx.doi.org/10.1016/j.ijmedinf.2005.07.004.

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Williams, D. D. R., Mary M. Ellis, and Fawzea Hardwick. "Intensive home nursing." Psychiatric Bulletin 21, no. 1 (January 1997): 23–25. http://dx.doi.org/10.1192/pb.21.1.23.

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This paper describes the establishment of a team of four nurses to provide a service in old age psychiatry along the lines of “Hospital At Home”. Its aim was to treat and nurse patients at home who otherwise would have to be admitted to hospital. An integral part of this initiative is the use of a problem orientated approach with integrated records. The work of the team over six years is reviewed and how it has evolved to provide a rapid response to difficult and fraught situations.

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Pokorski, Simoni, Maria Antonieta Moraes, Régis Chiarelli, Angelita Paganin Costanzi, and Eneida Rejane Rabelo. "Nursing process: from literature to practice. What are we actually doing?" Revista Latino-Americana de Enfermagem 17, no. 3 (June 2009): 302–7. http://dx.doi.org/10.1590/s0104-11692009000300004.

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OBJECTIVES: To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. METHODS: Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48h after admission. The form for data collection was structured according to other reports. RESULTS: 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. CONCLUSIONS: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

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Dalton, Bruce R., Deana M. Sabuda, Lauren C. Bresee, and John M. Conly. "Assessment of Antimicrobial Utilization Metrics: Days of Therapy Versus Defined Daily Doses and Pharmacy Dispensing Records Versus Nursing Administration Data." Infection Control & Hospital Epidemiology 36, no. 6 (March 30, 2015): 688–94. http://dx.doi.org/10.1017/ice.2015.46.

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OBJECTIVETo compare antimicrobial utilization data derived from pharmacy dispensing records and nursing administration record data by 2 commonly used units of measure.DESIGN, PARTICIPANTS, AND METHODSData from nursing administration records and pharmacy dispensing records were obtained for 32 medical wards. From nursing and pharmacy data, defined daily doses (DDD) were calculated, and from the nursing data, days of therapy were derived. Direct comparison of total antimicrobial use was performed by graphical analysis and linear regression. Slope of trend line was used to quantify the difference between pairs of measures. Bland-Altman plots were constructed to determine constant and proportional bias. At the level of individual agents, difference between pairs of measures was calculated and presented graphically and the average (95% CI) for the difference between measures was determined.RESULTSNursing administration record–derived DDD were on average 23% lower than corresponding rates of pharmacy dispensing record–derived DDD. The difference between rates of utilization by days of therapy vs DDD from the same source (nursing) was relatively small. Results from analysis of different individual agents were highly variable with wide 95% CIs.CONCLUSIONSIn our setting, we found clinically relevant differences in antimicrobial utilization associated with data from different sources. This outweighed the importance of the metric (DDD or days of therapy). However, measurement of use of individual agents was highly variable and sensitive to both metric unit and data sources.Infect Control Hosp Epidemiol 2015;00(0): 1–7

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Macieira, Tamara G. R., Tania C. M. Chianca, Madison B. Smith, Yingwei Yao, Jiang Bian, Diana J. Wilkie, Karen Dunn Lopez, and Gail M. Keenan. "Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review." Journal of the American Medical Informatics Association 26, no. 11 (June 12, 2019): 1401–11. http://dx.doi.org/10.1093/jamia/ocz086.

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Abstract Objective The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from electronic health records (EHRs). Materials and Methods We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment. Results Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling. Discussion SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes. Conclusions Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient’s health care experience.

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Chae, Sena, Hyunkyoung Oh, and Sue Moorhead. "Effectiveness of Nursing Interventions using Standardized Nursing Terminologies: An Integrative Review." Western Journal of Nursing Research 42, no. 11 (February 20, 2020): 963–73. http://dx.doi.org/10.1177/0193945919900488.

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The purpose of this integrative review is to synthesize recent literature that used NANDA International diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) to determine the effectiveness of nursing interventions and cost-analysis and to identify the direction for future effectiveness research using standardized nursing terminologies (SNTs). A search was performed using the Cumulative Index to Nursing and Allied Health Literature, Scopus, and KoreaMed, covering the period from 2003 to 2018. A total 267 articles were identified, and 24 articles were analyzed for this review. Eighteen studies evaluated the effectiveness of nursing interventions based on outcomes, and of those 18 studies, four examined the effectiveness based on the development of NNN linkages. Six studies analyzed the cost of nursing interventions. Integrating SNTs into electronic health records (EHRs), developing NNN linkages, and further effectiveness studies using SNTs are required to determine the value of nursing care to improve patient outcomes.

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Kim, Y., and H. A. Park. "Development and Validation of Detailed Clinical Models for Nursing Problems in Perinatal care." Applied Clinical Informatics 02, no. 02 (2011): 225–39. http://dx.doi.org/10.4338/aci-2011-01-ra-0007.

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SummaryObjectives: The aims of this study were to develop detailed clinical models (DCMs) for nursing problems related to perinatal care and to test the applicability of these detailed clinical models. Methods: First, we extracted entities of nursing problems by analyzing nursing-problem statements from nursing records, reviewing the literature, and interviewing nurse experts. Second, we extracted attributes and possible values needed to describe the entities in more detail by again analyzing nursing statements, reviewing the literature, and consulting nurse experts. Third, DCMs were modeled by linking each entity with possible attributes with value sets and optionalities. Fourth, entities, attributes and value sets in the DCMs were mapped to the International Classification for Nursing Practice (ICNP) version 2. Finally, DCMs were validated by consulting a group of experts and by applying them to real clinical data and nursing care scenarios published in the literature. The adequacy of the entities, attributes, value sets, and optionalities of the attributes were validated.Results: Fifty-eight entities were identified, 41 entities from nursing records, 12 entities from literature review and 5 entities from nurse experts. Sixty-five attributes with values were identified, 25 attributes from nursing records, 34 attributes from literature review, and 6 attributes from nurse experts. In total 58 DCMs were developed and validated.Conclusions: The DCMs developed in this study can ensure that electronic health records contain meaningful and valid information, and support the semantic interoperability of nursing information.

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Do, Taehee, and Heejung Kim. "Effects of nursing record education focused on legal aspects at small and medium sized hospitals." Journal of Korean Academic Society of Nursing Education 27, no. 2 (May 31, 2021): 152–62. http://dx.doi.org/10.5977/jkasne.2021.27.2.152.

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Purpose: The purpose of this study was to examine the effect of nursing record education on the knowledge and performance of nursing record of nurses at small- and medium-sized hospitals.Methods: The participants were 62 nurses working in two small- and medium-sized hospitals. Thirty-two nurses comprised the experimental group, and 30 nurses comprised the control group. Nursing record education was provided for the experimental group. Data were analyzed by x2-test and t-test analysis using the IBM SPSS statistics 25.0 Program. Results: After education, the knowledge (t=2.43, p=.019), performance (t=2.19, p=.033) and behavior scores (t=2.42, p=.018) on nursing record were significantly higher in the experimental group than in the control group. Based on this result, nursing record education is an effective intervention to improve nurses’ knowledge and performance in writing nursing records in small- and medium-sized hospitals. Conclusion: We suggest the development of a systematic and standardized education program on nursing record including its legal aspects, for nurses in small- and medium-sized hospitals. The results of this study can be used as basic data for developing a nursing record education program for small- and medium-sized hospitals.

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Saraswasta, I. Wayan Gede, and Rr Tutik Sri Hariyati. "The Implementation of Electronic based Nursing Care Documentation to EFETEC; A Literature Review." International Journal of Nursing and Health Services (IJNHS) 1, no. 2 (January 3, 2019): 19–31. http://dx.doi.org/10.35654/ijnhs.v1i2.23.

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ABSTRACT In last two decades most of the tasks performed by nurses have not been directly related to patient care. Nurses spend more time on writing documentation or medical records of patients. Implementation of electronic medical record can reduce the time used for documentation or in other hand will increase the time for nurses to interact with patients then eventually can improve the quality of nursing care. Purpose of this literature review is to find out the implementation of electronic-based nursing care documentation (EHR) in improving the quality of nursing care in terms of EFETEC aspects. Method used by author is a literature review. Database used is Science Direct, PROQUEST, Scopus, Ebscho and Scholar Article with the keywords; electronic health record, EHR, Documentation in nursing, Quality of nursing care. Implementation of electronic nursing care documentation can improve the service quality. Improvement of the quality of service is reviewed with EFETEC which consists of efficient, focus for patient, effective, time discipline, equality, confidentiality. In the era of health workers 4.0 the utilization of electronic nursing care documentation requires continuous development in order to improve the quality of service for patients. KEYWORDS: electronic health record, nursing care documentation, quality of nursing care

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Salgado, Patrícia de Oliveira, and Tânia Couto Machado Chianca. "Identification and mapping of the nursing diagnoses and actions in an Intensive Care Unit." Revista Latino-Americana de Enfermagem 19, no. 4 (August 2011): 928–35. http://dx.doi.org/10.1590/s0104-11692011000400011.

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This is a descriptive study with the aim of examining the nursing diagnoses labels and actions prescribed by nurses in the clinical records of patients hospitalized in an Adult Intensive Care Unit. A sample of 44 clinical records was obtained and a total of 1087 nursing diagnoses and 2260 nursing actions were identified. After exclusion of repetitions 28 different nursing diagnoses labels and 124 different nursing actions were found. Twenty-five nursing diagnoses labels were related to human psychobiological needs and three to psychosocial needs. All the nursing actions were mapped to the physiological needs and also to interventions of the Nursing Interventions Classification-NIC. Concordance of 100% was obtained between the experts in the validation process of the mapping performed, both for the nursing diagnoses labels and actions. Similar studies should be conducted for the identification and development of nursing diagnoses and actions.

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Oyama, Chiaki, and Fumiyo Fujino. "Home Nursing Care for Terminal Patients. An Analysis of Home Nursing using Visit Records." KITAKANTO Medical Journal 51, no. 5 (2001): 301–5. http://dx.doi.org/10.2974/kmj.51.301.

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Morales, Juan Miguel, M. M. Rodriguez, J. Terol, A. Torres, and J. M. Alvarez. "Nursing Records With Standardized Nursing Language in Prehospital Emergency Care: From Utopia to Reality." International Journal of Nursing Terminologies and Classifications 14, s4 (October 2003): 37. http://dx.doi.org/10.1111/j.1744-618x.2003.032_9.x.

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Ehnfors, Margareta. "Dokumentation of Patient Problems and Nursing Diagnoses in a Sample of Swedish Nursing Records." Nordic Journal of Nursing Research 14, no. 4 (December 1994): 14–18. http://dx.doi.org/10.1177/010740839401400404.

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Lee, Seon Heui, and Soyoung Yu. "Changes in nursing professions’ scope of practice: A pilot study using electronic nursing records." Health Policy and Technology 7, no. 1 (March 2018): 15–22. http://dx.doi.org/10.1016/j.hlpt.2017.12.003.

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Park, Hyunbong, Soyoung Yu, and Seon Heui Lee. "Evaluating the Correlation Between Nursing Practice and Electronic Nursing Records Using Importance-Performance Analysis." CIN: Computers, Informatics, Nursing 39, no. 9 (April 13, 2021): 492–98. http://dx.doi.org/10.1097/cin.0000000000000737.

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Kim, Kidong, Suyeon Jeong, Kyogu Lee, Hyeoun-Ae Park, Yul Min, Joo Lee, Yekyung Kim, Sooyoung Yoo, Gippeum Doh, and Soyeon Ahn. "Metrics for Electronic-Nursing-Record-Based Narratives: cross-sectional analysis." Applied Clinical Informatics 07, no. 04 (October 2016): 1107–19. http://dx.doi.org/10.4338/aci-2016-07-ra-0119.

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Summary ObjectivesWe aimed to determine the characteristics of quantitative metrics for nursing narratives documented in electronic nursing records and their association with hospital admission traits and diagnoses in a large data set not limited to specific patient events or hypotheses. MethodsWe collected 135,406,873 electronic, structured coded nursing narratives from 231,494 hospital admissions of patients discharged between 2008 and 2012 at a tertiary teaching institution that routinely uses an electronic health records system. The standardized number of nursing narratives (i.e., the total number of nursing narratives divided by the length of the hospital stay) was suggested to integrate the frequency and quantity of nursing documentation. ResultsThe standardized number of nursing narratives was higher for patients aged ≥ 70 years (median = 30.2 narratives/day, interquartile range [IQR] = 24.0–39.4 narratives/day), long (≥ 8 days) hospital stays (median = 34.6 narratives/day, IQR = 27.2–43.5 narratives/day), and hospital deaths (median = 59.1 narratives/day, IQR = 47.0–74.8 narratives/day). The standardized number of narratives was higher in “pregnancy, childbirth, and puerperium” (median = 46.5, IQR = 39.0–54.7) and “diseases of the circulatory system” admissions (median = 35.7, IQR = 29.0–43.4). ConclusionsDiverse hospital admissions can be consistently described with nursing-documentderived metrics for similar hospital admissions and diagnoses. Some areas of hospital admissions may have consistently increasing volumes of nursing documentation across years. Usability of electronic nursing document metrics for evaluating healthcare requires multiple aspects of hospital admissions to be considered. Citation: Kim K, Jeong S, Lee K, Park H-A, Min YH, Lee JY, Kim Y, Yoo S, Doh G, Ahn S. Metrics for electronicnursing-record-based narratives: cross-sectional analysis.

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Journal articles on the topic 'Nursing and nursing records'

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