Documentation in nursing practice

Owen, Kate

doi:10.7748/ns2005.04.19.32.48.c3846

Cited by 23 publications

(6 citation statements)

References 3 publications

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“…The second theme (Challenges) revealed a complex array of issues and concerns (i.e., 5 sub-themes) ranging from organizational issues to leadership and inter-disciplinary team support. From the sub-theme respecting organizational issues, participants cited lack of time as a major issue in this study, mirroring findings in many previous studies [20] [38] [39]. The participants in the current study stated that they had a heavy workload with the patients; this workload does not allow them time to document patient care.…”

Section: Discussionsupporting

confidence: 77%

“…The literature is replete with examples of barriers and challenges to nursing documentation [17] [18]. Some speak to time and resource constraints (i.e., workload) as major impediments to meeting the documentation expectations [19] [20]. Others cite lack of organizational commitment and institutional policies to the process as a significant barrier [9].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital

Nakate¹,

Dahl²,

Petrucka³

et al. 2015

OJN

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In Uganda, nursing documentation still remains a challenge, in most of the government hospitals and some private hospitals, it remains at a manual (non-technology driven) level and omissions have been observed. Nurses continue to capture standard elements in their documentation. A mixed methods intervention study was conducted to determine knowledge and attitudes of nurses towards documentation, including an evaluation of nurses' response to a designed nursing documentation form. Forty participants were selected through convenience sampling from six wards of a Ugandan health institution. The study intervention involved teaching nurses the importance of documentation and using of the trial documentation tool. Pre-and post-testing and open-ended questionnaires were used in data collection. The results from the close-ended questions were presented in the previous publication; the responses from the open-ended questions would then be presented. The open-ended questions regarding comments about the nursing documentation process and suggestions about the process of implementing the nursing documentation system in the ward units were considered. All participants were provided the opportunity to provide personal comments, reflections, or stories of their experiences with documentation in patient care. A thematic analysis approach was used during data analysis. The results showed that the participants had positive attitude towards documentation of patient care, but they had constraints limiting them to document, they reflected issues concerning the perceived pressure from the administra- G. M. Nakate et al. 1064 tions and support to document. The study findings have implication that there is need for organizational support and to have multisite studies and extension of the documentation tool.

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Section: Discussionsupporting

confidence: 77%

Section: Introductionmentioning

confidence: 99%

The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital

Nakate¹,

Dahl²,

Petrucka³

et al. 2015

OJN

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“…These findings are reflected by Cheevakasemsook et al (2006) and Owen (2005), who argue that nurse documentation and record-keeping is often improved by a reduction in duplication.…”

Section: Discussionmentioning

confidence: 48%

Improving nurse documentation and record keeping in stoma care

2010

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Evidence suggests that nurse documentation is often inconsistent and lacks a coherent and standardized approach. This article reports on research into the use of nurse documentation on a stoma care ward in a large London hospital, and explores the factors that may affect the process of record keeping by nursing staff. This study uses stoma care as a case study to explore the role of documentation on the ward, focusing on how this can be improved. It is based on quantitative and qualitative methods. The medical notes of 56 patients were analysed and in addition, focus groups with a number of nurses were undertaken. Quantitative findings indicate that although 80% of patients had a chart filed in their medical notes, only a small portion of the form was completed by nursing staff. Focus group findings indicate that this is because forms lacked standardization and because the language used was often ambiguous. Staff also felt that such documentation was not viewed by other nurses and so, was not effective in improving patient care. As a result of this study, significant improvements have been made to documentation used on the stoma care ward. This is an important exploration of record keeping within nursing in the context of the Nursing and Midwifery Council’s emphasis on the importance of documentation in achieving effective patient outcomes.

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“…Hal ini disebabkan oleh semua perawat mempunyai kewajiban yang sama dalam mendokumentasikan asuhan keperawatan yang telah dilakukan terhadap kliennya karena dokumentasi asuhan keperawatan merupakan salah satu aspek legal sebagai bentuk pertanggungjawaban perawat terhadap pasien, tanpa dipengaruhi oleh karakteristik responden (Owen, 2005).…”

Section: Pembahasanunclassified

Hubungan Motivasi dan Komitmen Organisasi dengan Kinerja Perawat dalam Pelaksanaan Dokumentasi Asuhan Keperawatan

Miladiyah

Mustikasari²,

Gayatri³

2015

JKI

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AbstrakMotivasi dan komitmen organisasi merupakan faktor yang meningkatkan dan membangun kinerja perawat secara konstruktif dalam menghasilkan kualitas asuhan keperawatan yang bermutu. Penelitian ini bertujuan untuk mengetahui hubungan motivasi dan komitmen organisasi dengan kinerja perawat dalam pelaksanaan dokumentasi asuhan keperawatan di sebuah Rumah Sakit di Bekasi. Jenis penelitian ini adalah deskriptif korelasi dengan rancangan cross sectional. Sampel penelitian ini adalah seratus enam perawat pelaksana dengan menggunakan kuesioner dan observasi dokumentasi asuhan keperawatan. Analisis dengan univariat, bivariat (chi square), dan multivariat (regresi logistik berganda). Hasil penelitian menunjukkan bahwa ada hubungan antara motivasi dan kinerja perawat dalam pelaksanaan dokumentasi asuhan keperawatan (p= 0,000; α= 0,05). Motivasi ekstrinsik memengaruhi kinerja perawat dua puluh enam kali lebih tinggi (OR= 26,708) setelah dikontrol oleh variabel umur, status kepegawaian, dan masa kerja. Perlu dilakukan audit dokumentasi sebagai bagian dari penilaian kinerja perawat.

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Documentation in nursing practice

Abstract: Accurate documentation is essential to maintain continuity and inform health professionals of ongoing care and treatment. It also provides legal evidence. This article highlights the advantages of accurate record keeping and the barriers to effective documentation in the community setting.

Cited by 23 publications

References 3 publications

The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital

The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital

Improving nurse documentation and record keeping in stoma care

Hubungan Motivasi dan Komitmen Organisasi dengan Kinerja Perawat dalam Pelaksanaan Dokumentasi Asuhan Keperawatan

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