Accuracy of documentation in the nursing care plan in long-term institutional care

Tuinman, Astrid; Greef, M.H.G. de; Krijnen, Wim P.; Paans, Wolter; Roodbol, Petrie F.

doi:10.1016/j.gerinurse.2017.04.007

Cited by 46 publications

(68 citation statements)

References 30 publications

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“…The current study conducted by Tuinman et al (2017) found inaccuracies in the content and coherence of nursing documentation in long-term institutional care. This may complicate communication between health professionals, data extraction by managers for quality and reimbursement purposes and also jeopardize residents' safety and wellbeing.…”

Section: Discussionmentioning

confidence: 56%

Nurses Education and Motivation Towards Nursing Documentation

Mediarti¹,

Rehana²,

Abunyamin³

2018

J. Ners

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Introduction: Nursing documentation is an integral part that cannot be separated from healthcare as a responsibility and accountability of nurses. High education and motivation are needed to achieve good nursing documentation. The aim of this study was to know the correlation between education and motivation of nurses towards Intensive Care nursing documentation.Methods: The design used was an analytical survey with a cross-sectional approach. The population was nurses in intensive care of Palembang BARI Hospital with as many as 46 nurses and 44 samples obtained with total sampling. Data were collected by questionnaire and observational and were analyzed by Chi-Square. Independent variables are education and motivation of nurses and the dependent variable is nursing documentation.Results: There was a correlation between education (p=0.035) and motivation (p=0.040) of nurses towards nursing documentation.Conclusion: High education and motivation of nurses influenced towards the quality of nursing education. The nursing manager of the hospital is recommended affording the opportunity to support human resources in the hospital, especially for nurses to participate in education, in accordance with the demands of legislation in nursing education, and to organize the training of nursing documentation.

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Section: Discussionmentioning

confidence: 56%

Nurses Education and Motivation Towards Nursing Documentation

Mediarti¹,

Rehana²,

Abunyamin³

2018

J. Ners

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“…Inadequacies in nursing documentation are frequently found in the documentation of patients’ care needs, interventions, and progress reports (Paans, Sermeus, Nieweg, & Van der Schans, ; Tuinman, De Greef, Krijnen, Paans, & Roodbol, ). These inadequacies are related to the fact that the nursing process is not always used as the point of departure in the documentation (Blair & Smith, ).…”

Section: Introductionmentioning

confidence: 99%

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews

Groot

Triemstra

Paans

et al. 2019

Journal of Advanced Nursing

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Aim To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. Design Systematic review of systematic reviews. Data sources We systematically searched the databases PubMed and CINAHL for the period 2007–April 2017. We also performed additional searches. Review methods Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis. Results Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence‐based instruments were described for assessing the quality of nursing documentation, such as the D‐Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user‐friendliness and development in consultation with nursing staff. Conclusion Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important for high‐quality nursing documentation. The lack of evidence‐based quality indicators presents a challenge in the pursuit of high‐quality nursing documentation. Impact There is uncertainty in nursing practice about which criteria have to be met to achieve high‐quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.

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“…They are best placed to identify adverse events in the process of care, due to their central role in the provision of care, along with their holistic knowledge of the patient [34,35]. They are more likely to report errors via error-reporting systems than other healthcare staff [36], attributed to their feeling of a moral obligation to provide safe care to patients [12,37,38].…”

Section: Introductionmentioning

confidence: 99%

Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

et al. 2020

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Patient safety is crucial for the sustainability of the healthcare system. However, this may be jeopardized by the high prevalence of practice errors, particularly in residential long-term care. Development of improvement initiatives depends on full reporting and disclosure of practice errors. This systematic review aimed to understand factors that influence disclosing and reporting practice errors by nurses in residential long-term care settings. A systematic review using an integrative design was conducted. Electronic databases including PubMed (including Medline), Scopus, CINAHL, Embase, and Nordic and Spanish databases were searched using keywords relating to reporting and disclosing practice errors by nurses in residential long-term care facilities to retrieve articles published between 2010 and 2019. The search identified five articles, including a survey, a prospective cohort, one mixed-methods and two qualitative studies. The review findings were presented under the categories of the theoretical domains of Vincent’s framework for analyzing risk and safety in clinical practice: ‘patient’, ‘healthcare provider’, ‘task’, ‘work environment’, and ‘organisation & management’. The review findings highlighted the roles of older people and their families, nurses’ individual responsibilities, knowledge and collaboration, workplace atmosphere, and support by nurse leaders for reporting and disclosing practice errors, which had implications for improving the quality of healthcare services in residential long-term care settings.

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Accuracy of documentation in the nursing care plan in long-term institutional care

Cited by 46 publications

References 30 publications

Nurses Education and Motivation Towards Nursing Documentation

Nurses Education and Motivation Towards Nursing Documentation

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews

Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

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