Documentation: Communicating Professionalism

Fox-Ungar, Elise; Newell, G. Kathleen; Guilbault, K

doi:10.1097/00006247-198901000-00017

Cited by 3 publications

(2 citation statements)

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“…Documentation of care planning is seen as a punishment and a chore imposed by administrators (Sutcliffe 1990). The literature further suggests that care plans are viewed as unimportant, are not valued (Fox Ungar, Newel1 & Guilbalt 1989), and rarely developed or followed (Costello & Summers 1985).…”

Section: Introductionmentioning

confidence: 99%

Developing care plan documentation: an action research project

1995

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Section: Introductionmentioning

confidence: 99%

Developing care plan documentation: an action research project

1995

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“…Use of the nursmg process m the A/E setting is made infinitely more difficult by several factors (Walton 1986) These m-e recognized by Bradley (1985) as short stay of the pahents, vanety of the presaitmg problems, tradihonal athtude that nurses shck to ngid routmes and do not have time to give mdividualized pahent care, strong influence of medical model, records are tmw-consuming m the emergency settmg and are not a pnonty, and plannmg carmot occur when it is so busy The development of the nursmg record m A/E department m the UK has taken place very recently and no comprehensive hterature has yet been published Work pubhshed m the USA has identified that A/E nurses lack a umque identity so there is BO reason to have separate nursmg records (Novotny-Dmsdale 1985, Larson 1986 The problem as it stands is that nursmg care as a theory-based subject is neither important nor valued Therefore, nurses feel powerless and lack confidence m their role (Fox-Ungar et al 1989) Monger & Wachsmuth (1986) agree with the nohon that charhng m A/E appears to lack structure and was perceived as hme<onsummg Therefore, charting tends to be neglected, parhcularly m regard to the less senously lU or mjured pahents (Monger & Wachsmuth 1986, Ruth 1986…”

Section: Documentation Of Care In the Accident And Emergency Departmentmentioning

confidence: 99%

Does the use of an assessment tool in the accident and emergency department improve the quality of care?

Christie

1993

Journal of Advanced Nursing

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The aim of this study was to evaluate the effect of introducing a nursing record, using the SOAPE model, in the accident and emergency department. A working group was formed to design and implement a new record and evaluate its effect. A 6-month teaching programme was run to prepare staff. Quality of documentation was measured using the Phaneuf Audit Tool both before and after the implementation of the new record and the teaching sessions. The results were compared. It was concluded that, overall, the documentation showed significant improvement. Therefore, it could be assumed that there had been an improvement in the quality of care.

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The Complexities of Documenting Clinical Information in Long-term Care Settings in Australia

Pelletier¹,

Duffield²,

Gietzelt³

et al. 2002

J Gerontol Nurs

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Clinical nursing documentation, written, verbal or supported by technology, is being affected by both the worldwide "information explosion" and budgetary constraints. In Australia, the necessity of documenting complex care needs and treatment plans in older adult care settings has become more imperative because funding levels and sources are frequently tied to these documents. As a consequence, the statutory requirements for documentation have become a significant driving force in shaping nursing practice. Although the value of quality documentation is or should be recognized, the seemingly vast amounts of time required inevitably distracts nurses from what they see as their primary purpose-the provision of direct patient care. Older adults who are frail are among the most complex clients requiring services in what is traditionally a poorly resourced sector. Under-funding frequently impacts on the staff skill mix, resulting in low levels of senior, highly qualified, and skilled staff. These factors impact the quality of the documentation and possibly the usage of the information itself. This article will provide an overview of the issues related to documentation of clinical information in older adult care settings with particular reference to some of the "unique" inefficiencies inherent in the Australian system.

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Documentation: Communicating Professionalism

Cited by 3 publications

References 0 publications

Developing care plan documentation: an action research project

Developing care plan documentation: an action research project

Does the use of an assessment tool in the accident and emergency department improve the quality of care?

The Complexities of Documenting Clinical Information in Long-term Care Settings in Australia

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