Long‐term increase in quality of nursing documentation: effects of a comprehensive intervention

Abstract

This study aimed to evaluate the longitudinal effects of a nursing-documentation intervention on the quantity and quality of the nursing documentation in a sample of patient records at a university hospital in Stockholm, Sweden. In this quasi-experimental longitudinal study, two hospital wards participated in a 2-year intervention and a third ward was used for comparison. The intervention consisted of organizational changes and education regarding nursing documentation in accordance with the VIPS model, a model designed to structure nursing documentation. To evaluate the effect, patient records were audited at three different time points: before the intervention, directly after the intervention and 3 years after the intervention. A total of 269 patient records were used. The findings showed a significant score increase in quantity as well as in quality of the nursing documentation, in the intervention wards directly after the intervention, as compared with those from the comparison ward. The results suggests that a comprehensive intervention based on the VIPS model and including organizational support for registered nurses (RN) may improve nursing documentation in an acute care hospital setting.

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

“…To the best of our knowledge, no other studies in nursing homes have shown the effects of using a CDSS on the completeness and comprehensiveness of nursing documentation, though several studies have shown improved documentation after educational interventions in paper-based [40,47] and electronic health records [39,48].…”

Amming kartlagt ved rutinedata

“…For eksempel var deltakerprosen- (20). Studier fra skolehelsetjenesten har vist at helsesøstre finner det uproblematisk å dokumentere fysisk helse i journalen (21), men sykepleiedokumentasjon kan påvirkes av organisatoriske forandringer (22). En ammekyndig helsestasjon skal ifølge retningslinjene kartlegge ammeforekomsten og arbeide for å fremme amming.…”

Forskrivning, bruk og dokumentasjon av effekt

“…Tidligere studier har vist at mangel på tid, ansattes holdninger, ledelsens fokus på legemiddelkunnskap hos de ansatte og opplaering innen dokumentasjonsarbeid, påvirker dokumentasjonshyppighet og -kvalitet (23)(24)(25)(26). Ved ikke å dokumentere effekten av legemidler pasienten tar, kan pasientsikkerheten trues.…”