How to undertake effective record-keeping and documentation

Brooks, Nicola

doi:10.7748/ns.2021.e11700

Cited by 5 publications

(2 citation statements)

References 3 publications

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“…Beyond training, nurses are often streamlined into specialty and subspeciality based areas of care (e.g., urology) and become highly experienced in providing appropriate postoperative management. Nurses ensure execution of postoperative interventions and care plans, monitor and assess patients closely for clinical deterioration and perform effective record keeping and documentation to support the provision of safe, high‐quality patient care 26 …”

Section: Discussionmentioning

confidence: 99%

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Active involvement of nursing staff in reporting and grading complication‐intervention events—Protocol and results of the CAMUS Pilot Nurse Delphi Study

et al. 2022

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Objectives: The aim of this study is to gain experienced nursing perspective on current and future complication reporting and grading in Urology, establish the CAMUS CCI and quality control the use of the Clavien-Dindo Classification (CDC) in nursing staff. Subjects and Methods:The 12-part REDCap-based Delphi survey was developed in conjunction with expert nurse, urologist and methodologist input. Certified local and international inpatient and outpatient nurses specialised in urology, perioperative nurses and urology-specific advanced practice nurses/nurse practitioners will be included. A minimum sample size of 250 participants is targeted. The survey assesses participant demographics, nursing experience and opinion on complication reporting and the proposed CAMUS reporting recommendations; grading of intervention events using the existing CDC and the proposed CAMUS Classification; and rating various clinical scenarios. Consensus will be defined as ≥75% agreement. If consensus is not reached, subsequent Delphi rounds will be performed under Steering Committee guidance.Results: Twenty participants completed the pilot survey. Median survey completion time was 58 min . The survey revealed that 85% of nursing participants believe nurses should be involved in future complication reporting and grading but currently have poor confidence and inadequate relevant background education.Overall, 100% of participants recognise the universal demand for reporting consensus and 75% hold a preference towards the CAMUS System. Limitations include variability in nursing experience, complexity of supplemental grades and survey duration.

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Section: Discussionmentioning

confidence: 99%

“…Nurses ensure execution of postoperative interventions and care plans, monitor and assess patients closely for clinical deterioration and perform effective record keeping and documentation to support the provision of safe, high‐quality patient care. 26 …”

Section: Discussionmentioning

confidence: 99%

Active involvement of nursing staff in reporting and grading complication‐intervention events—Protocol and results of the CAMUS Pilot Nurse Delphi Study

et al. 2022

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Nurses’ ethical responsibilities: Whistleblowing and advocacy in patient safety

Ibrahim

2024

Nurs Ethics

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Background In the dynamic landscape of healthcare, nurses play a crucial role as ethical stewards, responsible for whistleblowing, nurse advocacy, and patient safety. Their duties involve ensuring patient well-being through ethical practices and advocacy initiatives. Aim This study investigates the ethical responsibilities of nurses regarding whistleblowing and advocacy in reporting concerns about patient safety. Research Design A cross-sectional study utilized cluster and simple random sampling to gather a representative sample of actively practicing registered nurses. Data collection involved a demographic form, Nurse Whistleblowing Intentions Scale, Nursing Advocacy Scale, and Clinical Decision-Making Scale. Participants and Research Context The study utilizing a robust sample size determination formula for reliable findings included 96 diverse nurses, predominantly females. Engaged actively in direct patient care across various outpatients clinics. The recruitment process specifically sought individuals with expertise in safety protocols and reporting, contributing to a nuanced understanding of the study’s focus. Ethical Considerations Ethical approval was obtained from the ethics committee of the university and the hospitals involved. Written consent was obtained from the participants. A thorough ethical review was conducted to guarantee participant protection and adherence to ethical principles. Results Surveyed nurses demonstrated positive whistleblowing (Overall Mean Score: 3.58), high advocacy (Overall Mean Score: 12.2), and nuanced ethical decision-making for patient safety (Overall Mean Score: 15.78). Demographic factors, such as nationality and ethical training, significantly impacted whistleblowing intentions, while age, gender, and ethical training correlated with nursing advocacy behavior. Associations with experience and qualification emerged in ethical decision-making. Conclusion The gained insights foster targeted interventions, improving ethical practices, advocacy, and informed decision-making in nursing. This study explores the intricate link between demographics and ethical considerations among surveyed nurses, acting as a catalyst for ongoing initiatives to strengthen the ethical foundation in healthcare sector.

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Validação de instrumento para Registro do Processo de Enfermagem no atendimento pré-hospitalar móvel de urgência

et al. 2023

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Objetivo: validar a aparência e o conteúdo de um instrumento para Registro do Processo de Enfermagem no Serviço de Atendimento Móvel de Urgência. Método: estudo de abordagem quantitativa, em que o instrumento foi submetido à validação de aparência e conteúdo por comitê de 21 experts na área de atendimento pré-hospitalar móvel de urgência nacionalmente. Um Índice de Validade de Conteúdo (IVC) igual ou superior a 0,80 estabeleceu a validação. Resultados: obteve-se um IVC de 0,94. Apenas o item facilidade de leitura, relacionado à aparência, teve um índice abaixo do estabelecido. Foi possível avaliar as 99 intervenções de Enfermagem elencadas. Conclusão: o instrumento para Registro do Processo de Enfermagem no Serviço de Atendimento Móvel de Urgência foi considerado válido e pode possibilitar a documentação manual da prática do enfermeiro neste cenário.

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How to undertake effective record-keeping and documentation

Cited by 5 publications

References 3 publications

Active involvement of nursing staff in reporting and grading complication‐intervention events—Protocol and results of the CAMUS Pilot Nurse Delphi Study

Active involvement of nursing staff in reporting and grading complication‐intervention events—Protocol and results of the CAMUS Pilot Nurse Delphi Study

Nurses’ ethical responsibilities: Whistleblowing and advocacy in patient safety

Validação de instrumento para Registro do Processo de Enfermagem no atendimento pré-hospitalar móvel de urgência

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