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

Akhu‐Zaheya, Laila; AbuAlRub, Raeda; Hani, Salam Hasan Bany

doi:10.1111/jocn.14097

Cited by 133 publications

(155 citation statements)

References 36 publications

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“…The nurses are subject to working in wards with heavy workloads due to the unpredictability of events, interruptions and multi‐task requirements (Baethge, Müller, & Rigotti, ). Our research confirms the results of previous studies in which nurses say that one of the reasons they do not individualise SCP is because they feel they have an excessive workload (Akhu‐Zaheya et al, ; Banamwana & Smith, ; Pöder, Fogelberg‐Dahm, & Wadesten, ). In addition is the fact that nurses perceive they have been allocated too many patients, affecting the quality and safety of the care (Aiken et al, ; Cho et al, ; Kim & Bae, ), as well as the use of individualised care plans (Agyeman‐Yeboah, Korsah, & Okrah, ; Mayilvaganan, ; Rose, ).…”

Section: Discussionsupporting

confidence: 90%

“…The nurses of our study claim that supervisors should be responsible for planning the care properly. In the research conducted by Akhu‐Zaheya, Al‐Maaitah, and Hani () one of the reasons that explains why the nursing process is not adequately recorded is the nurse leaders' failure to monitor the process. These leaders usually check the nursing records based on the number of records made, instead of evaluating the quality of the content.…”

Section: Discussionmentioning

confidence: 99%

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Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

Castellà-Creus

Delgado‐Hito

Casanovas-Cuellar

et al. 2019

Journal of Clinical Nursing

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Objective To identify and classify the barriers and facilitators of the individualisation process of the standardised care plan in hospitalisation wards. Background The administration of individualised care is one of the features of the nursing process. Care plans are the structured record of the diagnosis, planning and evaluation stages of the nursing process. Although the creation of standardised care plan has made recording easier, it is still necessary to record the individualisation of the care. It is important to study the elements that influence the individualisation process from the nurses' perspective. Design Qualitative study with the grounded theory approach developed by Strauss and Corbin. Methods Thirty‐nine nurses from three hospitals participated by way of theoretical sampling. In‐depth interviews were conducted, as well as participant observation, document analysis and focus group discussion. The analysis consisted of open, axial and selective coding until data saturation was reached. EQUATOR guidelines for qualitative research (COREQ) were applied. Results For both barriers and facilitators, three thematic categories emerged related to organisational, professional and individual aspects. The identified barriers included routines acquired in the wards, the tradition of narrative records, lack of knowledge and limited interest in individualisation. The identified facilitators included holding clinical care sessions, use of standardised care plan and an interface terminology, the nurse's expertise and willingness to individualise. Conclusion The individualisation process of the standardised care plan involves multiple barriers and facilitators, which influence its degree of accuracy. Relevance to clinical practice Implementing strategies at an organisational level, professional level and individual level to improve the way the process is carried out would encourage individualising the standardised care plan in a manner that is consistent with the needs of the patient and family; it would improve the quality of care and patient satisfaction.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

Castellà-Creus

Delgado‐Hito

Casanovas-Cuellar

et al. 2019

Journal of Clinical Nursing

View full text Add to dashboard Cite

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“…Accurate registration, which can be facilitated through using computer programs (10)(11) , is pointed out in the literature as a way to improve communication among professionals (1)(2)(3) , to ensure the care continuity plans (12) , as well as the integrity and regularity of patient information (13) . These aspects should be highlighted when initiating a program to encourage adoption of the NP and the documentation resulting from it.…”

Section: Np Implementation and Documentationmentioning

confidence: 99%

Documentação do processo de enfermagem em instituições públicas de saúde

Azevedo

Guedes

Araújo

et al. 2019

Rev. esc. enferm. USP

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RESUMO Objetivo Identificar a prevalência de documentação do Processo de Enfermagem nos hospitais e ambulatórios administrados pela Secretaria de Estado da Saúde de São Paulo. Método Estudo descritivo, realizado por meio de entrevistas com enfermeiros responsáveis por 416 setores de 40 instituições sobre a documentação de quatro fases do Processo de Enfermagem (levantamento de dados, diagnóstico, prescrição e evolução) e de anotações de enfermagem. Resultados Dos 416 setores estudados, 89,9% documentavam pelo menos uma fase; 56,0% documentavam as quatro fases; 4,3% documentavam apenas anotações de enfermagem; 5,8% não documentavam nenhuma fase, nem as anotações de enfermagem. Os tipos de setores que menos documentavam foram: ambulatório, apoio diagnóstico, centro cirúrgico e centro obstétrico; os que mais documentavam: unidades de terapia intensiva, prontos-socorros e unidades de internação. O levantamento de dados e o diagnóstico foram as fases menos documentadas, ambas em 78,8% dos setores. Conclusão A maior parte dos setores estudados documenta o Processo de Enfermagem e faz anotações de enfermagem, mas há setores em que a documentação não corresponde às exigências formais. A viabilidade da documentação de todas as fases do Processo de Enfermagem em determinados tipos de setores precisa ser mais bem estudada.

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“…In this regard, it should be noted that nursing records are indicators of quality of care provided. However, the literature points to a practice that demonstrates the poor quality of care documentation, (17) even in relation to the nursing process, (18) whose instrument subsidizes Nursing Consultation.…”

Section: Discussionmentioning

confidence: 99%

Desdobramentos judiciais do erro na enfermagem

et al. 2019

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Objective: To characterize lawsuits with judicial decisions by errors involving nursing professionals. Methods: A documentary study, with cases judged and concluded that dealt with error involving nursing professionals. The survey was carried out in May and June 2018, on the online website of the Court of Justice of Paraná State. The information of interest was place of occurrence, professionals involved, characteristics of victims, error and outcome of the investigation. For analysis, the data were submitted to descriptive statistics. Results: There were 31 cases judged, most of which occurred in a hospital (90.32%) and with adults (64.71%). In eight cases, the victim died; in half, the victims had temporary disability (17.50%); seven people had permanent disability. The most frequent error involved medication administration (38.71%), followed by delivery error (19.35%). In more than half of the cases, police report card was registered by the victim (58.06%) and only one medical expert was consulted during the lawsuit (61.29%). In 22 cases, the professional was convicted. Of these, 20 were civil and two criminal convictions. On average, civil lawsuits generated reimbursement of about 10,654 US dollars. In criminal cases, the average length of imprisonment converted into community services was 18 months. Conclusion: Lawsuits culminated in convictions. In addition, they point to the need for better structure and support for professionals who undergo legal experience. ResumoObjetivo: Caracterizar processos com decisões judiciais por erros envolvendo profi ssionais de enfermagem. Métodos: Estudo documental, com os casos julgados e concluídos, que versavam sobre erro envolvendo profi ssionais de enfermagem. O levantamento foi realizado nos meses de maio e junho de 2018, no sítio online do Tribunal de Justiça do Paraná. As informações de interesse foram: local da ocorrência, profi ssionais envolvidos, características das vítimas, do erro e o desfecho da investigação. Para análise os dados foram submetidos à estatística descritiva. Resultados: Foram identifi cados 31 casos julgados, cuja maioria ocorreu em ambiente hospitalar (90,32%), com indivíduos adultos (64,71%). Em oito casos a vítima foi a óbito, em metade deles apresentou incapacidade temporária (17=50%) e sete pessoas apresentaram incapacidade permanente. O erro mais frequente envolveu a administração de medicamentos (38,71%), seguido por erro de assistência ao parto (19,35%). Em mais da metade dos casos o boletim de ocorrência foi registrado pela própria vítima (58,06%) e somente um perito médico foi consultado durante o processo (61,29%). Em 22 casos o profi ssional foi condenado. Destes, 20 foram condenações cíveis e duas criminais. Em média, os processos cíveis geraram ressarcimento de R$ 42.614,30 reais e nos processos criminais, a média de tempo de reclusão, convertidos em serviços comunitários foi de 18 meses. Conclusão: Os processos judiciais culminaram em condenações. Além disso, apontam à necessidade de melhor estrutura e apoio aos profi ssionais que...

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

Cited by 133 publications

References 36 publications

Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

Documentação do processo de enfermagem em instituições públicas de saúde

Desdobramentos judiciais do erro na enfermagem

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