Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital

Abstract

Discussions on how nursing documentation should be carried out have been ongoing for the last decade. In this study, free-text format for nursing diagnoses was introduced to nursing staff at a university hospital in Norway. The aim of the study was to investigate the impact of an education intervention introducing nursing diagnoses in a free-text format following a problemetiology-symptom structure. A pretest-posttest design was performed to assess changes in quality and quantity in the nursing documentation using the audit instrument N-Catch II. Several elements in the nursing documentation had statistically significant changes; the largest was found for quantity in nursing diagnoses. Education interventions aimed to improve nurses' documentation in the electronic health record may have an effect on more complete and accurate nursing documentation. The presented education intervention showed a significant impact of more accurate nursing diagnoses and significant improvements in nursing documentation.

Quality of nursing documentation: Paper‐based health records versus electronic‐based health records

“…This is because these unexpected findings also confirm the poor education, lack of training of nurses and insufficient knowledge of the nursing process including nursing diagnosis. Previous studies revealed that educational programmes directed at improving diagnostic reasoning skills significantly increase the prevalence and accuracy of documented nursing diagnoses (Bruylands et al., ; Nøst, Frigstad, & André, ). In addition, lack of follow‐up and periodic auditing of nursing documentation records from the quality department might not only initiate bad practice and poor content by nurses’ documentation, but it also reflects the looseness and weakness of the quality assurance and monitoring system of the hospitals.…”

How implementation of “Joy of Life” are experienced by the employees: A qualitative study

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Effects of Problem, Intervention, Evaluation (PIE) training on the Quality of Nursing Documentation Among Students of Hamadan University of Medical Sciences, Hamadan, Iran

“…Hemmati Maslakpak et al indicated that problembased documentation training increased the mean scores of nurses' reports (8). Nost et al (16) and Muller-Staub (20) found that educational interventions, such as problembased reporting methods, have significant effects on increasing the accuracy and reporting of nurses' diagnoses, interventions, and treatment outcomes and lead to the quality improvement of nursing reports. The results of a study by Abbaszadeh et al also showed a significant difference in the mean performance score of nurses in documentation between the pretest and posttest (14).…”