The Quality of Clinical Documentation of Patients Admitted to an Iranian Teaching Hospital: A two-year Impact of Clinical Governance

Dehghan, Dorsa; Dehghan, Mahlagha; Sheikhrabori, Akbar

doi:10.5958/2349-2996.2015.00033.6

Cited by 3 publications

(5 citation statements)

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“…Thirty two studies used new forms as one of their strategies for improving nursing documentation (Aparanji et al, 2018; Björvell et al, 2002; Bono, 1992; Cahill et al, 2011; Chineke et al, 2020; Christie, 1993; Dahlstrom et al, 2011; de Rond et al, 2000; Dehghan et al, 2015; Elliott et al, 2017; Ellis et al, 2007; Enright et al, 2015; Florin et al, 2005; Förberg et al, 2012; Gerdtz et al, 2013; Gordon et al, 2008; Hayter & Schaper, 2015; Higuchi et al, 1999; Hospodar, 2007; Hübner et al, 2015; Kamath et al, 2011; Karp et al, 2019; Khresheh & Barclay, 2008; Mansfield et al, 2001; Mitchell et al, 2010; Nomura et al, 2018; Nøst et al, 2017; O’Connor et al, 2014; Stewart et al, 2009; Stocki et al, 2018; Thoroddsen & Ehnfors, 2007; Unaka et al, 2017). Seventeen of the 32 studies had a final compliance rate ≥ 70%.…”

Section: Resultsmentioning

confidence: 99%

“…Prompts were used in four of the studies (Chineke et al, 2020;Hom et al, 2019;Kamath et al, 2011;Sandau et al, 2015), and except for Sandau et al (2015) they all had a final compliance of ≥ 80%. Thirty two studies used new forms as one of their strat-egies for improving nursing documentation (Aparanji et al, 2018;Björvell et al, 2002;Bono, 1992;Cahill et al, 2011;Chineke et al, 2020;Christie, 1993;Dahlstrom et al, 2011;de Rond et al, 2000;Dehghan et al, 2015;Elliott et al, 2017;Ellis et al, 2007;Enright et al, 2015;Florin et al, 2005;Förberg et al, 2012;Gerdtz et al, 2013;Gordon et al, 2008;Hayter & Schaper, 2015;Higuchi et al, 1999;…”

Section: Resultsmentioning

confidence: 99%

“…It should be noted that the results for Elliott (2018) must be used with caution as some neg-ative results may have left out in the final calculation of compliance rates. Ten studies included administrative or system changes as one of the strategies to improve nursing documentation (Ammenwerth et al, 2001;Dehghan et al, 2015;Enright et al, 2015;Gerdtz et al, 2013;Kamath et al, 2011;Mansfield et al, 2001;Meyer et al, 2019;Okoyo Nyakiba et al, 2014;Stewart et al, 2009;Trad et al, 2019). All of the system changes improved nursing documentation, six of them had a final compliance rate ≥70% (Ammenwerth et al, 2001;Enright et al, 2015;Kamath et al, 2011;Mansfield et al, 2001;Meyer et al, 2019;Stewart et al, 2009).…”

Section: Resultsmentioning

confidence: 99%

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Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Bunting¹,

Klerk²

2022

SAGE Open Nursing

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Introduction This systematic review attempts to answer the following question – which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting? Methods A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020. Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles. The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance. Results Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020. Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%. Conclusion Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Bunting¹,

Klerk²

2022

SAGE Open Nursing

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“…In the practice of documenting, it is recommended to record care as soon as it is provided, identify risks or problems that have arisen, fill in all records accurately and without any falsification, record your own notes in the documentation without unnecessary abbreviations (with a precise date and time), keep the documentation safe, and process and store research data and results accordingly (Nursing and Midwifery Council, 2015). Foreign studies point to a lack of nursing care tracking in line with holistic approach, legislation and professional standards (Dehghan et al, 2015;Gunningberg et al, 2008;Høgsnes et al, 2016;Vainiomäki et al, 2008;Wang et al, 2011). In Slovakia, the proper management of nursing documentation is the legislative and professional requirement of nursing practice, which is also the basis for the creation of contracts between health care providers and the health insurance company.…”

Section: Introductionmentioning

confidence: 99%

The issue of documenting pressure ulcers: literary review

Kačalová¹,

Žiaková²

2019

Kontakt

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Objective: To find, analyze and compare clinical recommended practices, national recommendations, guidelines, nursing standards and assessment tools with a focus on documenting pressure ulcers. Methodology: The selection of relevant sources was carried out in 2018 using search services and sources in electronic databases (Medline, ProQuest, PubMed), book publications, from professional societies, and professional journals. Out of 139 sources, 38 sources were selected and processed in three phases based on the ranking and exclusion criteria. Results: By analyzing and comparing clinically recommended procedures, national recommendations, guidelines, nursing standards and assessment tools to document pressure ulcers, we have found that the most frequently reiterated requirement for pressure ulcers is: degree of pressure ulcer, its location, size, base, exudate and surroundings. The most observed items that tell us about documenting of the pressure ulcer healing process are found in the NPUAP, EPUAP, PPPIA consensus (GRADE), HSE, AAWC, and RNAO guidelines. Conclusions: Pressure ulcer documenting is a problem addressed within national and international recommendations or guidelines. Their analysis and comparison revealed several worldwide unified documentation requirements, which are essential to multidisciplinary collaboration and decision-making on further treatment.

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“…Audit of records provides important information on pressure ulcer recording (Hansen and Fossum, 2016); well-documented documentation is a source of information and a tool for assessing the effectiveness or inefficiency of nursing activities (Somrová and Bártlová, 2012). Some foreign studies also point to a lack of nursing care records in line with a holistic approach, legislation and professional standards (Dehghan et al, 2015;Gunningberg et al, 2008;Høgsnes et al, 2016;Vainiomäki et al, 2008;Wang et al, 2007). In Slovakia, the use of a specific assessment tool is not required for the assessment of pressure ulcer assessment, but the correct entry of the necessary data, which should contain a brief description of the performance and evaluation, according to the applicable legislation in the .…”

Section: Introductionmentioning

confidence: 99%

Documentation of the treatment of pressure ulcers in home care agencies and welfare institutions in the Slovak Republic

Kačalová¹,

Žiaková²

2019

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Objective: To analyze the documentation of pressure ulcers at home care agencies (HCA) and welfare institutions (WI) to determine whether the records comply with legislative and contractual requirements. Methods: Empirical data were collected from the documentation containing the Nursing Care Proposal (Proposal), the Course of disease, the Expert Findings, and the Records of examinations and prescription drugs for the treatment of pressure ulcer in the Health Insurance Information System (HIIS). Data collection was carried out from the year 2014 to 2018. Documentation of 101 patients treated for pressure ulcer which were reported to the General Health Insurence Company, a.p. (GHIC) for paymant, were included in the research file. Descriptive, frequency analysis methods were used to evaluate the results. Results: Correct recording of localization, size, number and codes, less consistent writing of base, margins, secretion, and pressure ulcer surroundings. The analysis pointed to shortcomings in documenting continuous information on the pressure healing process and the diversity in the frequency of documenting the pressure ulcer healing process. 65.3% of the patients were treated by a specialist. The identity of the drugs reported in the HCA/WI documentation with the drugs reported in the HIIS was 46.5%. Conclusions: Problems in recording nursing care of pressure ulcers are mainly in the area of unstructured records of pressure ulcer healing process and in the uniformity of recorded information on applied drugs in nursing documentation and in HIIS.

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The Quality of Clinical Documentation of Patients Admitted to an Iranian Teaching Hospital: A two-year Impact of Clinical Governance

Cited by 3 publications

References 0 publications

Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

The issue of documenting pressure ulcers: literary review

Documentation of the treatment of pressure ulcers in home care agencies and welfare institutions in the Slovak Republic

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