Evaluating nursing documentation – research designs and methods: systematic review

Saranto, Kaija; Kinnunen, Ulla‐Mari

doi:10.1111/j.1365-2648.2008.04914.x

Cited by 135 publications

(154 citation statements)

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“…A structured format for recording has been effective at increasing the quality of nursing documentation [39,49]. A study conducted in a Swedish hospital showed that both the quality and comprehensiveness of PU documentation significantly improved after implementing an EHR system with pre-formulated templates [39]; however, the study had a before-after design with no control group.…”

Section: Discussionmentioning

confidence: 99%

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Fossum

Ehnfors

Svensson

et al. 2013

International Journal of Medical Informatics

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Background: Nursing documentation is essential for facilitating the flow of information to guarantee continuity, quality and safety in care. High-quality nursing documentation is frequently lacking; the implementation of computerized decision support systems is expected to improve clinical practice and nursing documentation. Aim:The present study aimed at investigate the effects of a computerized decision support system and an educational program as intervention strategies for improved nursing documentation practice on pressure ulcers and malnutrition in nursing homes.Design, setting and participants: An intervention study with two intervention groups and one control group was used. Fifteen nursing homes in southern Norway were included. A convenience sample of electronic healthcare records from 46 units was included. Inclusion criteria were records with presence of pressure ulcers and/or malnutrition. The residents were assessed before and after an intervention of a computerized decision support system in the electronic healthcare records. Data were collected through a review of 150 records before (2007) Methods:The nurses in intervention group 1 were offered educational sessions and were trained to use the computerized decision support system, which they used for eight months in 2008 and 2009. The nurses in intervention group 2 were offered the same educational program but did not use the computerized decision support system. The nurses in the control group were not subject to any intervention. The resident records were examined for the completeness and comprehensiveness of the documentation of pressure ulcers and malnutrition with three data collection forms and the data were analyzed with non-parametric statistics. Results:The implementation of the computerized decision support system and the educational program resulted in a more complete and comprehensive documentation of pressure ulcer-and malnutrition-related nursing assessments and nursing interventions. Conclusion:This study provides evidence that the computerized decision support system and an educational program as implementation strategies had a positive influence on nursing documentation practice.Key words: decision support system, documentation, intervention studies, malnutrition, nursing audit, pressure ulcer. Highlights A computerized decision support system and an educational program were implemented. The computerized decision support system provided evidence-based interventions. The implementation resulted in a more complete and comprehensive documentation. The total number of documented nursing problems was relatively low.

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Section: Discussionmentioning

confidence: 99%

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Fossum

Ehnfors

Svensson

et al. 2013

International Journal of Medical Informatics

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“…The importance of information about clients and care in the operation of modern health care organisations has been well recognized [1,2,3]. Information systems that facilitate data collection and tracking for patient care can also sustain care quality improvement [4].…”

Section: Introductionmentioning

confidence: 99%

Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities

Wang

Hailey

2013

International Journal of Medical Informatics

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Purpose To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records. Methods Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level. Results Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p < 0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p < 0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p < 0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p < 0.01), suggesting more items designed in a form, more information would be captured. Conclusion Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content. Website: http://www.uow.edu.au/~ping/ Key words: electronic health record, paper record, electronic record, nursing documentation, admission form, auditing, quality, evaluation.-2 - AbstractPurpose: To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records.Methods: Retrospective auditing and comparison of the documentation quality of paperbased and electronic resident admission forms were conducted. A checklist...

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“…A review suggests that standardized documentation is associated with more positive than negative effects, for example regarding main outcomes as quality and content. [4] Also, documentation has been shown to be important in relation to mortality, as it was found that certain patterns of nursing documentation within electronic health records could be used to predict patient mortality. [43] An ethnographic study carried out in a medical ED found that nurses tended to document screenings supporting a flow culture, where the primary objective for ED nurses were to secure free beds for the next patients.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3] Furthermore, documentation is necessary for patient safety and continuity. [3][4][5] Even though documenting patient data has been a nursing task for more than 150 years, [6] and the exchange of information is a significant nursing activity, [3] documentation practices is still today an area of extensive challenges. [7][8][9][10][11] Increased requirements for documentation and demands to fulfill quality standards are a part of everyday practice in Danish hospitals, as patient treatment and trajectories are getting more complex.…”

Section: Introductionmentioning

confidence: 99%

An evaluation of nursing documentation of acutely admitted older home-living medical patients in a Danish hospital

Sivertsen

Juul‐Larsen

Petersen

et al. 2017

CNS

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Background: Documentation enhances patient safety and continuity. According to national Danish guidelines, nursing documentation should contain core areas such as: nutritional status, pain, sleep, urinary-and bowel elimination, skin and tissue, cognitive and psychosocial factors. Documentation practice and its association to patient impairments have not been examined as a comprehensive, combined set of nursing core areas in acutely admitted older medical patients. Therefor the objective of this study was to examine levels of nursing documentation and the associations between documentation levels and patient impairments. Methods: A descriptive study of acutely admitted patients above 65 years old. Audit of handwritten nursing records and structured patient interviews were conducted to assess eight core areas based on the national Danish guidelines for nursing documentation: nutritional status, pain, sleep, urinary-and bowel elimination, skin and tissue, cognitive and psychosocial factors. Furthermore measures of Charlson Comorbidity Index (CCI) and self-reported health were collected. Results: 90 acutely admitted medical patients ≥ 65 years were enrolled. The prevalence of documentation was between 4 and 80%. We found a higher prevalence of unstructured documentation. Looking at six of the eight core areas, 33% of the patients had 0-2 areas documented. For all the eight core areas we found no difference in the prevalence of documentation for patients with impairment compared to patients without impairment, nor did we find a significant association between patient documentation and age, sex, CCI, or self-rated health. Conclusions:The results implies that something else than national guidelines, patient impairments, age, sex, CCI and self-rated health of the patient are determining whether documentation is done or not.

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Evaluating nursing documentation – research designs and methods: systematic review

Cited by 135 publications

References 50 publications

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities

An evaluation of nursing documentation of acutely admitted older home-living medical patients in a Danish hospital

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