Effect of Nanda-I, Nic, and Noc Documentation System Training on Quality of Nursing Care Documentation in the Perinatal Ward of Yogyakarta Regional Public Hospital

Setyaningrum, Enny Eko; Nurjannah, Intansari; Rustiyaningsih, Anik

doi:10.33546/bnj.770

Cited by 7 publications

(4 citation statements)

References 21 publications

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“…Indikator atau kriteria hasil luaran keperawatan memang tidak memiliki patokan khusus, namun dibebaskan berdasarkan proses berpikir kritis dan penalaran klinis perawat (Xiao et al, 2017). Hal ini yang sering menjadi kendala bagi perawat yang baru mengenal dan menggunakan standar NOC, namun kendala tersebut dapat dikurangi atau bahkan dihilangkan dengan mengikuti pelatihan (Setyaningrum et al, 2019).…”

Section: Pembahasanunclassified

Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan

Koerniawan¹,

Daeli²,

Srimiyati³

2020

JKS

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This study aims to look at the quality of nursing care documentation at Myria Hospital Palembang. Analytic surveys are used to obtain an overview of nursing documentation as secondary data. Nursing care documents used were 105 documents by cluster sampling and measured using Q-DIO instruments, and analyzed descriptively. The results showed most of the medium quality in all dimensions, namely diagnosis as a process of 70 documents (67%), diagnosis as a product as many as 56 documents (53%), intervention as many as 66 documents (63%), and nursing outcomes as many as 67 documents (64%). The conclusions in this study indicate that 67% of records have moderate quality on the dimensions of diagnosis as a process, 53% of documents have a reasonable condition on the aspects of diagnosis as a product, 63% of records have moderate quality on the dimensions of intervention, and 64% of documents have average quality on the dimensions of output nursing. The results of the nursing process that have been obtained in this study illustrate the change or improvement in the improvement of symptoms that have a moderate quality to integrate with the nursing process. Keywords: Diagnosis, Documentation, Intervention, Output

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Section: Pembahasanunclassified

Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan

Koerniawan¹,

Daeli²,

Srimiyati³

2020

JKS

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“…Using standardized nursing terminology in nursing diagnoses helps to improve the quality of nursing records (Setyaningrum et al, 2019), by improving accuracy of documentation, staff competence, and critical thinking skills (Hasegawa et al, 2007;Inan & Dinç, 2013). Several studies have revealed that the nurses' attitude toward the usage of nursing diagnoses has changed after the NANDA-I, II taxonomy trainings (Collins, 2013) and there have been significant improvements in documentation (Fernanda Da Costa Linch et al, 2017;Müller-Staub et al, 2008).…”

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confidence: 99%

The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records

Nool

Tupits

Parm

et al. 2022

Int J of Nursing Knowl

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Aim The aim of the paper is to compare the quality of nursing documentation in the Children's Hospital before and after the NANDA‐I nursing diagnoses training. Methods Research employed the interventional study design, and pre–post study design. Before and after the NANDA‐I nursing diagnoses training, 50 nursing records were analyzed in the interventional pre–post study, using D‐Catch instrument. Results The most often documented problem‐centered nursing diagnosis before training was anxiety and after the training, hyperthermia. The most common risk diagnoses before and after the training was risk of infection. Before the training, one health promotion diagnosis was determined in the nursing records, and after the training the number increased to four. The highest value was given to readability of the nursing documentation both before and after the training. The lowest score before the training was given to the quality determiners of the accurate nursing diagnoses and after the training given to the determiners of the results’ quantity. The sum score of documenting the nursing interventions was the most inconsistent before the training and after the training. The most consistent was the readability of the nursing records before and after the training. Statistically significant differences in the improvement of quality were revealed in all areas except for the readability of the nursing documentation and the quantity of nursing assessment. Conclusions The results of the study revealed that following the training, the quality of nursing documentation improved, the wording of the nursing diagnoses improved, and the number of accurate nursing diagnoses had increased. Implications for Nursing Practice Results of the research provide an overview of the importance of the training in improving the quality of nursing documentation and aid the educators in planning the trainings, focusing more on the challenges in the documentation.

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“…2 Nessa perspectiva, pesquisadores de todo o mundo têm demonstrado preocupação em realizar uma avaliação fidedigna da qualidade dos registros de enfermagem, a partir de um instrumento validado, como o Q-DIO. [7][8][9] No continente americano, em especial no Brasil, a utilização do Q-DIO enquanto instrumento avaliativo ainda é incipiente, estando limitada a avalição de registros de unidades de internação clínicas. 10 Considerando a relevância dos registros de enfermagem completos e redigidos de forma clara e objetiva como forma de garantir e evidenciar a qualidade dos cuidados prestados, tem-se a seguinte questão de pesquisa: como se apresentam os registros do PE, em relação à qualidade, mensurados pelo Q-DIO em uma unidade de terapia intensiva (UTI) adulto?…”

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“…Enferm. UFSM, v.12, p.[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] 2022 Ao analisar esse condicionante na literatura,23 a falta de tempo tem sido considerada como principal condicionante para não realizar ou realizar de forma incompleta os registros da evolução de enfermagem. Atrelado a esse fator, destaca-se o excesso de atribuições do enfermeiro e da inexistência de um modelo para o registro das evoluções.Como resultado do estudo, pôde-se identificar que a etapa da evolução de enfermagem é a mais negligenciada dentre as etapas do PE, a considerar que elas não constam junto dos registros de enfermagem referentes ao PE, mas sim em folhas à parte, que ficam junto dos demais documentos do prontuário do paciente.…”

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Avaliação dos registros de enfermagem por meio do Quality of Diagnoses, Interventions and Outcomes

et al. 2022

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Objetivo: avaliar a qualidade dos registros do Processo de Enfermagem em prontuários de uma unidade de terapia intensiva adulto. Método: estudo transversal, com aplicação do Quality of Diagnoses, Interventions and Outcomes em 145 prontuários de pacientes que estiveram internados no período de novembro de 2018 a junho de 2019. Resultados: em relação ao domínio denominado Diagnósticos de Enfermagem como processo, apenas 27% dos registros apresentaram-se completos. No domínio Diagnósticos de Enfermagem como produto, os resultados foram satisfatórios com 97% da documentação completa. A satisfatoriedade se manteve nas Intervenções de Enfermagem, em que a completude foi obtida em 94% dos prontuários. Quanto aos Resultados, mais da metade dos registros apresentaram inconsistências. Conclusão: os registros do Processo de Enfermagem vêm sendo executados na unidade de terapia intensiva de forma parcialmente satisfatória, e, a partir deste estudo, é possível desenvolver estratégias para melhoria da qualidade dos registros.

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Effect of Nanda-I, Nic, and Noc Documentation System Training on Quality of Nursing Care Documentation in the Perinatal Ward of Yogyakarta Regional Public Hospital

Cited by 7 publications

References 21 publications

Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan

Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan

The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records

Avaliação dos registros de enfermagem por meio do Quality of Diagnoses, Interventions and Outcomes

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