Effects on the Quality of the Nursing Care Process Through an Educational Program and the Use of Electronic Nursing Documentation

Bruylands, Michelle; Paans, Wolter; Hediger, Hannele; Müller‐Staub, Maria

doi:10.1111/j.2047-3095.2013.01248.x

Cited by 51 publications

(74 citation statements)

References 28 publications

(64 reference statements)

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“…The evaluation started in the first record (admission or first evolution). This period is determined according to the recommendations of the Quality of Diagnosis, Interventions and Outcomes (Q-DIO) 7 - 8 . There was no collection of patient information, such as age or diagnosis, and there were no interviews, since those were not the focus of the study or part of the instrument items.…”

Section: Methodsmentioning

confidence: 99%

“…It can be used for electronic or paper records and for nursing records with or without standardized language. This instrument was developed and validated in 2007 and published in 2009 by researchers from Switzerland, the Netherlands and the United States of America 7 . The Q-DIO version for use in Brazil has been published recently 8 .…”

Section: Methodsmentioning

confidence: 99%

“…The instrument is a Likert scale composed of 29 items divided in four concepts: nursing diagnoses as process (11 items), nursing diagnoses as product (eight items), nursing interventions (three items) and nursing outcomes (seven items). The scores range from 0 to 2 for all items, 0 being undocumented, 1 partially documented and 2 fully documented 7 - 8 .…”

Section: Methodsmentioning

confidence: 99%

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An educational intervention impact on the quality of nursing records

Linch

Lima

Souza

et al. 2017

Rev. Latino-Am. Enfermagem

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Objective:to evaluate the impact of an educational intervention on the quality of nursing records. Method:quasi-experimental study with before-and-after design conducted in a hospital. All the nurses in the cardiac intensive care unit of the hospital received the intervention, which consisted of weekly meetings during five months. To collect data, the instrument Quality of Diagnoses, Interventions and Outcomes was applied to the patients’ charts in two moments: baseline and after intervention. Results:the educational intervention had an impact on the quality of the records, since most of the items presented a significant increase in their mean values after the intervention, despite the low values in the two moments. Conclusion:the educational intervention proved to be effective at improving the quality of nursing records and a lack of quality was identified in the evaluated records, revealed by the low mean values and by the weakness of some questions presented in the items, which did not present a significant increase. Therefore, educational actions focused on real clinical cases may have positive implications for nursing practice.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

An educational intervention impact on the quality of nursing records

Linch

Lima

Souza

et al. 2017

Rev. Latino-Am. Enfermagem

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“…However, constant support and the use of support tools are crucial strategies for high quality of NP documentation. (12) …”

Section: Discussionmentioning

confidence: 99%

Construção e implantação do Histórico de Enfermagem em Terapia Intensiva Pediátrica

et al. 2016

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1Universidade Federal do Maranhão, São Luís, MA, Brasil. Conflicts of interest: there are no conflicts of interest to declare. AbstractObjective: To develop and implement a nursing patient history planning care in pediatric intensive care. Methods: A qualitative and descriptive study, with support of a bibliographical research and convergent care, conducted in the pediatric intensive care unit of a university hospital, involving the participation of 13 nurses. Group meetings, workshops and participant observation were the methodological resources for conducting the research. Results: Fourteen Basic Human Needs and scientific evidence underpin the development of the nursing patient history, composed of seven blocks arranged in a checklist format with open spaces for recording complications and nurse impressions. An instruction guide was provided to facilitate its use. Implementation was preceded by a test phase and historical validation. Conclusion: The instrument was developed based on scientific evidence, and included contributions from the nurses. The participatory involvement of nurses favored the implementation and use of the nursing patient history in care practices. ResumoObjetivo: Construir e implantar o Histórico de Enfermagem para planejamento dos cuidados em terapia intensiva pediátrica. Métodos: Estudo descritivo de abordagem qualitativa com suporte da Pesquisa Bibliográfica e da Convergente Assistencial. Realizado na terapia intensiva pediátrica de um hospital universitário envolvendo a participação de 13 enfermeiros. Encontros grupais, oficinas e observação participante foram os recursos metodológicos para condução da pesquisa. Resultados: Catorze evidências científicas e as Necessidades Humanas Básicas embasaram a construção do Histórico constituído por sete blocos organizados no formato check-list com espaços livres para registro de intercorrências e impressões do enfermeiro. Para facilitar sua utilização, foi construído guia de instruções. A implantação foi precedida pela fase de teste e validação do histórico. Conclusão: O instrumento foi construído fundamentado em evidências científicas e contou com contribuições dos enfermeiros do serviço. O envolvimento participativo dos enfermeiros favoreceu a implantação e utilização do Histórico nas práticas de cuidado.

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“…It eases the teaching, research and emancipation of clients in the therapeutic plan. (1,2) In this scenario, the assessment of nursing diagnoses in specific populations allows knowing altered human responses, contributing to reach an individualized and holistic assistance. (3) Several authors have focused on identifying nursing diagnoses in specific groups, like the elderly with cardiac insufficiency, patients of surgical clinic, oncologic clinic, the elderly, transplanted patients etc.…”

Section: Introductionmentioning

confidence: 99%

Diagnósticos de enfermagem em clínica cirúrgica

2015

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Objective: To identify the frequency of nursing diagnosis in patients in surgical clinic. Methods: A transverse, descriptive and exploratory study of quantitative approach, with data referring to 28 patients. The data collection instrument was developed by the researchers based on health functional patterns. Results: In total, 301 nursing diagnosis were found, with an average of 12 per patient. Only four diagnoses showed frequency above 50 percent. The most frequent were 'risk for infection', 'impaired skin/tissue integrity', 'readiness for enhanced spiritual well-being', 'sexual dysfunction' and 'disturbed sleep pattern'. The diagnoses that fit in domain 13 (Growth/Development) were not documented in this sample. Conclusion: The findings demonstrated a wide variety of diagnoses in the study population, a reflex of the diversity of care provided. Identifying the care needs favors the implantation of specific interventions, contributing to the quality of nursing assistance. ResumoObjetivo: Identificar a frequência dos diagnósticos de enfermagem em pacientes de clínica cirúrgica. Métodos: Estudo transversal, descritivo e exploratório, de abordagem quantitativa, com dados referentes a 28 pacientes. O instrumento de coleta de dados foi desenvolvido pelos pesquisadores, com base em padrões funcionais de saúde. Resultados: Foram encontrados 301 diagnósticos de enfermagem, com média de 12 por paciente. Somente quatro diagnósticos apresentaram frequência acima de 50%. Os mais frequentes foram: "risco de infecção", "integridade da pele/tissular prejudicada", "disposição para bem-estar espiritual", "disfunção sexual" e "padrão do sono perturbado". Diagnósticos que se enquadram no domínio 13 (Crescimento/Desenvolvimento) não foram documentados nesta amostra. Conclusão: Os achados demostraram ampla variedade de diagnósticos na população estudada, reflexo da diversidade de cuidados a serem prestados. A identificação das necessidades de cuidados favorece a implantação de intervenções específicas, contribuindo para a qualidade da assistência de enfermagem.

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Effects on the Quality of the Nursing Care Process Through an Educational Program and the Use of Electronic Nursing Documentation

Abstract: High-quality nursing documentation requires recognition of factors obstructing or supporting nurses in the use of e-docs while conducting the nursing process.

Cited by 51 publications

References 28 publications

An educational intervention impact on the quality of nursing records

An educational intervention impact on the quality of nursing records

Construção e implantação do Histórico de Enfermagem em Terapia Intensiva Pediátrica

Diagnósticos de enfermagem em clínica cirúrgica

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