Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

Wang, Ning; Hailey, David; Yu, Ping

doi:10.1111/j.1365-2648.2011.05634.x

Cited by 197 publications

(259 citation statements)

References 79 publications

(213 reference statements)

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“…Nursing records are more than the records of care which is planned and given to individual residents [41]. They can be the evidence used for quality assurance, legal purposes, health planning, allocation of resources and nursing development and research [42]. The quality of nursing records was improved in two aspects: format and content.…”

Section: Improved Quality Of Nursing Documentationmentioning

confidence: 99%

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

Zhang

Shen

2012

International Journal of Medical Informatics

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Purpose: Information and communications technology solutions have been introduced into the residential aged care system in order to improve the effectiveness and efficiency of aged care, however to date, the actual benefits have not been systematically analysed. The aim of this study was to identify the benefits of electronic health records (EHR) in residential aged care services and to examine how the benefits have been achieved. Method: A qualitative interview study was conducted in nine residential aged care facilities (RACFs) belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members selected through theoretical sampling, representing all levels of care staff who worked in those facilities. Results: Three categories of benefits were perceived by the care staff members according to who gain the benefits: the benefits to individual care staff members, to residents and to the RACFs. The benefits to individual care staff members include an improvement of documentation efficiency, information and knowledge growth as well as empowering the staff; the benefits to residents are an improvement in the quality of individual residents' health records, the higher quality of care and smoother communication between the residents and aged care staff; the RACFs gain an increased ability to manage information and acquire funding, an increase in their ability to control the care quality and improvements in the working environment and educational benefits. Three factors leading to these benefits were examined: the nature of the aged care EHR systems in comparison with paper-based records; the way the systems were used by the staff and one benefit that could lead to another. Conclusions: In this study, EHR systems were perceived to have substantial benefits for care staff, residents and the aged care organisations introducing the systems. The benefits were derived from the nature of the aged care EHR systems, staff members' continuous use of the systems, and one benefit led to the other. -2 - AbstractPurpose: Information and communications technology solutions have been introduced into the residential

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Section: Improved Quality Of Nursing Documentationmentioning

confidence: 99%

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

Zhang

Shen

2012

International Journal of Medical Informatics

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“…Dokumentasjon av sykepleie skal synliggjøre hvilke beslutninger som tas i utøvelse av sykepleie. Beslutningene vises gjennom sykepleiediagnoser, tiltak og en evaluering av prosess og utfall (4). Svakheter i dokumentasjonen av sykepleie skyldes ofte at det er utilstrekkelig dokumentasjon av psykologiske, sosiale, kulturelle og åndelige aspekter ved sykepleie, og at det legges for stor vekt på biomedisinsk dokumentasjon i sykepleie.…”

Section: Utviklet Icnp-katalogunclassified

“…Sykepleiediagnoser er ofte unøyaktige når det gjelder pasientens tilstand og gir i mange tilfeller uttrykk for medisinske diagnoser. Dette kan føre til at feilaktige eller lite hensiktsmessige sykepleietiltak blir iverksatt (4,16).…”

Section: Utviklet Icnp-katalogunclassified

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Felles fagspråk i sykepleie=dokumentasjon

Laukvik¹,

Mølstad²,

Fossum³

2017

Sykepleien

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“…Nursing records are an important tool of communication between staff; they are essential for planning care and to indicate the continuity and individuality of care (29) .…”

Section: Knowledge About Care Promotes Professional Autonomymentioning

confidence: 99%

Treatment of skin lesions in newborn children: meeting the needs of nursing staff

Santos

Costa

2014

Rev. esc. enferm. USP

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Treatment of skin lesions in newborn children: meeting the needs of nursing staff RESUMEN Objetivo: Conocer, junto al equipo de enfermería, los cuidados necesarios para el tratamiento de lesiones de piel en recién nacidos internados en una Unidad Neonatal. Método: Investigación cualitativa del tipo Convergente Asistencial. Los datos fueron obtenidos por medio de entrevistas semiestructuradas, realizadas en los meses de noviembre a deciembre de 2012, en la Unidad Neonatal de un hospital del Sur de Brasil. Participaron de la investigación cuatro auxiliares de enfermería, seis téc-nicos de enfermería y cuatro enfermeras. Resultados: Se originaron tres categorías: dudas acerca de lo que se puede utilizar en el recién nacido; la estancia hospitalaria puede causar lesiones en la piel del recién nacido; y el conocimiento del cuidado promueve autonomía profesional. Conclusión: Se hace urgente la necesidad de conocimiento del equipo acerca del tratamiento de las lesiones, a fin de proporcionar una atención más segura al recién nacido y favorecer la autonomía del profesional enfermero en la puesta en marcha del cuidado. DESCRIPTORES ABSTRACTObjective: to understand, together with nursing staff, the care needed to treat skin lesions in newborn children hospitalized in a neonatal unit. Method: qualitative research, of the convergent care type. The data was collected through semi-structured interviews, which were conducted from November to December 2012, in the neonatal unit of a hospital in southern Brazil. The participants were four auxiliary nurses, six nursing technicians and four nurses. Results: the following three categories were designated: questions about what can be used in relation to newborn children; hospitalization can cause lesions on the skin of newborn children; and knowledge about care promotes professional autonomy. Conclusion: there is an urgent need for staff to know more about the treatment of skin lesions, which would provide safer care for newborn children and would also support the autonomy of professional nurses in providing that care.

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Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

Abstract: Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

Cited by 197 publications

References 79 publications

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

Felles fagspråk i sykepleie=dokumentasjon

Treatment of skin lesions in newborn children: meeting the needs of nursing staff

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