Nursing documentation audit – the effect of a VIPS implementation programme in Denmark

Darmer, Mette Rosendal; Ankersen, Lena; Nielsen, Bettina Geissler; Landberger, Gitte; Lippert, Elisabeth; Egerod, Ingrid

doi:10.1111/j.1365-2702.2006.01475.x

Cited by 48 publications

(67 citation statements)

References 13 publications

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“…It has also been shown that nurses need strong managerial support in order to keep a high quality documentation of nursing care (34). Darmer has also showed that spending course of nursing documentation may promote knowledge of nurses about the principles of documentation (35). In the present study, a direct correlation was observed between the quality of care and the duration of hospitalization of patients with traction.…”

Section: Discussionsupporting

confidence: 64%

Quality of Care of Patients With Traction in Shahid Beheshti Hospital in 2012

Adib-Hajbaghery

Moradi

2013

Arch Trauma Res

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Background: With increasing incidence of traumatic fractures, the use of orthopedic intervention such as traction has increased. Inappropriate traction care may cause substantial morbidity and delay the patient rehabilitation. Objectives: This study was conducted to evaluate the quality of care for patients with traction in the orthopedic unit of Shahid-Beheshti Hospital, Kashan, Iran. Patients and Methods: This observational study was conducted on 100 patients with traumatic fractures of hip and femur bones who were admitted to Kashan Shahid-Beheshti Hospital during the first 6 months of 2012, and for whom skeletal or skin traction was performed. Data were collected using a checklist including questions about the personal characteristics and 23 items related to care for patients with tractions. These items were in three domains including caring while establishing traction, recording care and patient's education. Descriptive statistics were calculated and data were analyzed using the independent sample t-test and Pearson correlation coefficient. Results: The mean age of patients was 51.16 ± 23.28 years and 66% of them were male. In total, 47% of the patients were treated by skin traction and 53% by skeletal traction. The overall mean score of quality of care was 10.20 ± 2.64. Quality of establishing traction was good in 55% of patients, but the quality of care was poor in the domains of recording care (88%) and patient education (96%). Total mean of quality of care was significantly different between male and female patients (P < 0.02).Conclusions: The quality of care of patients with traction was not optimal. Therefore, it is necessary to improve measures in this area.

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Section: Discussionsupporting

confidence: 64%

Quality of Care of Patients With Traction in Shahid Beheshti Hospital in 2012

Adib-Hajbaghery

Moradi

2013

Arch Trauma Res

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“…1-2015, 11 årgang _________________________________________________________________________________________ Intervensjonen hadde en varighet på seks måneder hvorav tiden fra undervisning for siste undervisningsgruppe til avslutning av pilotperioden, var ni uker. Sammenlignet med andre studier (Müller-Staub et al 2006, Darmer et al 2006, Björvell et al 2002 er det kort tid for endring av arbeidsprosesser. Funnene gir indikasjon på at de ansatte er i en prosess, og selv om de ga uttrykk for at de ikke opplevde å vaere i mål, var dokumentasjonspraksisen i endring.…”

Section: Gjennomførbarhet Og Erfaringer Med Intervensjonenunclassified

“…For å lykkes med implementering innenfor sykepleiedokumentasjon, er betydningen av fokus på Nordisk Tidsskrift for Helseforskning nr. 1-2015, 11 årgang _________________________________________________________________________________________ organisatoriske faktorer, samt ferdigheter og samspillet med andre faggrupper beskrevet som sentralt (Darmer, Ankersen, Nielsen, Landberger, Lippert, Egerod 2006, Axelsson et al 2006, Björvell et al 2003, Müller-Staub 2009. Betydningen av menneskelige og organisatoriske faktorer er trukket frem som saerlig viktige (Lorenzi og Unertl 2012).…”

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Sykepleieres erfaringer med innføring av sykepleiediagnoser

Nøst

Blekken²,

André³

2015

NorTidHelse

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“…granskningsinstrumentet Det vil alltid vaere en viss grad av subjektivitet ved vurdering av sykepleiedokumentasjon (17,26,29). I brukerveiledningen til Cat-ch-Ing er kriterier for vurdering beskrevet.…”

Section: Intervensjonenunclassified

“…Bruk av sykepleiediagnoser kan forbedre kvalitet på dokumenterte vurderinger av pasienten, beskrevne tiltak og resultat, samt lette kommunikasjon og kontinuitet mellom aktører i helsetjenesten (13,15,19). Sykepleiediagnoser kan slik vaere et virkemiddel for å fremme og bedre dokumentasjonsprosessen (13,14,16,17). Sykepleiediagnoser kan enten formuleres ved å anvende klassifikasjonssystemer med spesifiserte termer, eller i fritekst (12,(19)(20)(21).…”

Section: Introduksjonunclassified

Implementering av sykepleiediagnoser i fritekst

Nøst¹,

Blekken²,

André³

2014

Sykepleien

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Background:The need for good nursing documentation has been highlighted by the Coordination Reform and several studies indicate that nursing documentation does not maintain the purpose of documentation. International studies have shown that implementation of nursing diagnoses has an effect on the quality in nursing documentation. Collaboration between a hospital and a university college was established to study the implementation of nursing diagnoses. This article describes the result from a pilot study of the project. Objective: The pilot study aims to investigate whether the audit instrument in the study is sensitive to change in the nursing documentation after an intervention with teaching and supervision on nursing diagnosis with P(R)ES-structure. Method:The study was a quantitative study with pre-test/post-test design. Data were collected by using Cat-ch-Ing. The intervention consists of teaching and supervision of nursing documentation.Results: There were no significant changes in the quality or quantity in the nursing documentation between pre-test and post-test design. Nursing documentation written as continuing documentation has a higher score than processes-oriented documentation. The audit instrument did not reflect all the changes the researchers experienced in the documentation. Conclusion:Assessment of the audit instrument Cat-ch-Ing indicates a need for more adequate scoring for nursing diagnosis in particular, and nursing documentation in general. There is a need for more knowledge about nursing documentation and what nurses need as working tools in clinical practice.

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Nursing documentation audit – the effect of a VIPS implementation programme in Denmark

Cited by 48 publications

References 13 publications

Quality of Care of Patients With Traction in Shahid Beheshti Hospital in 2012

Quality of Care of Patients With Traction in Shahid Beheshti Hospital in 2012

Sykepleieres erfaringer med innføring av sykepleiediagnoser

Implementering av sykepleiediagnoser i fritekst

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