Impact of primary care management on nursing documentation

Abstract

Positive perceptions of nursing documentation are bases for further development to a nursing documentation including a holistic view of the patient.

A meta‐study of the essentials of quality nursing documentation

“…Further to the discussion of how nurses should present their documentation to ensure that they meet legal requirements, they are advised to document the patient's condition and care in a manner that explains why decisions about that care were made 55 . Therefore, again, it must be reiterated that nursing documentation must be more than a list of tasks performed by the nurse.…”

Hospital Information Technology Systems' Impact on Nurses and Nursing Care

“…36 Of the studies that found no change in documentation quality, one study investigated whether a manager influenced the quality of nursing documentation and found no association between nurse satisfaction with a nurse manager and documentation quality. 40 The other study found that although there was no change in documentation quality with HIT, the time spent on documentation decreased, and some of those time savings were spent on direct patient care. 15 …”

“…23,40,[61][62][63] In the 2 cases in which attitude was negative, changes in nursing workflow 22 and organizational changes 31 that occurred at the time of HIT implementation might explain nurses' attitudes toward HIT. These studies advise that nursing leadership plays an integral role in the success of HIT.…”

Forskrivning, bruk og dokumentasjon av effekt

“…Tidligere studier har vist at mangel på tid, ansattes holdninger, ledelsens fokus på legemiddelkunnskap hos de ansatte og opplaering innen dokumentasjonsarbeid, påvirker dokumentasjonshyppighet og -kvalitet (23)(24)(25)(26). Ved ikke å dokumentere effekten av legemidler pasienten tar, kan pasientsikkerheten trues.…”