The quality of home care nurses’ documentation in new electronic patient records

Gjevjon, Edith Roth; Hellesø, Ragnhild

doi:10.1111/j.1365-2702.2009.02953.x

Cited by 50 publications

(68 citation statements)

References 29 publications

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“…Studies have shown that implementing an EHR does not unilaterally indicate that documentation comprehensiveness will increase [38,60]. Further studies should focus on nurses' actual knowledge in specific areas that CDSSs are designed to support, and these studies should evaluate the effects of CDSSs on nurses' knowledge in these specific areas.…”

Section: Discussionmentioning

confidence: 99%

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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%

“…The CIND has five ordered levels of increasing comprehensiveness (Table 3), and scores of 3, 4 and 5 meet the Norwegian recommendations [23]. The CIND has been used in several other studies, and tests of inter-rater reliability have produced Cohen's kappa values between 0.57 and 1.0 [25,[37][38][39][40][41].…”

Section: Data Collection and Outcome Measuresmentioning

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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show abstract

“…Additionally, health care professionals in hospitals are obligated to advise and guide the municipal health care services about patients’ needs [20, 21]. Research has shown, however, that documentation of basic health care needs [22], as well as communication of these needs across health care settings, is generally poor [23–27]. …”

Section: Introductionmentioning

confidence: 99%

Documentation and communication of nutritional care for elderly hospitalized patients: perspectives of nurses and undergraduate nurses in hospitals and nursing homes

et al. 2016

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BackgroundNutritional care is a basic human right for all people. Nevertheless, undernourishment is known to be a frequent and serious health care problem among elderly hospitalized patients in Western Europe. Nutritional documentation contributes to ensuring proper nutritional treatment and care. Only a few studies have explored how nurses document nutritional care in hospitals, and between hospitals and nursing homes. Available research suggests that documentation practices are unsatisfactory. The aim of this study was to explore how nurses document nutritional treatment and care for elderly patients in hospitals and how nurses and undergraduate nurses communicate information about patients’ nutritional status when elderly patients are transferred between hospital and nursing homes.MethodsA qualitative study was conducted using a phenomenological-hermeneutic approach. Data was collected in focus group interviews with 16 nurses in one large university hospital, and 11 nurses and 16 undergraduate nurses in five nursing homes associated with the university hospital. Participants from the university hospital represented a total of seven surgical and medical wards, all of which transferred patients to the associated nursing homes. The catchment area of the hospital and the nursing homes represented approximately 10% of the Norwegian population in heterogenic urban and rural municipalities. Data were coded and analysed thematically within the three contexts: self-understanding, critical common sense, and theoretical understanding.ResultsThe results were summarized under three main themes 1) inadequate documentation of nutritional status on hospital admission, 2) inadequate and unsystematic documentation of nutritional information during hospital stay, 3) limited communication of nutritional information between hospital and nursing homes. The three main themes included seven sub-themes, which reflected the lack of nutritional screening and unsystematic documentation on admission and during hospital stay. Further the sub-themes elucidated poor exchange of information between hospital and nursing homes regarding the nutritional status of patients.ConclusionOverall, the documentation of nutritional treatment and care for elderly patients was inadequate in the hospital and between health care settings. Inappropriate documentation can create a negative nutritional spiral that leads to increased risk of severe health related complications for elderly patients. Moreover, it hinders nutritional follow-up across health care settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s12912-016-0193-z) contains supplementary material, which is available to authorized users.

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“…«Nedsatt evne til verbal kommunikasjon, relatert til afasi etter slag, fører til frustrasjon og nedstemthet» er et eksempel på en sykepleiediagnose med P(R)ES-struktur. Det er beskrevet at strukturerte og standardiserte maler bidrar til en mer fullstendig dokumentasjon (8,19,23,24). Det er også vist til at bruk av standardiserte terminologier forbedrer innhold i sykepleieplaner i tillegg til å øke antall intervensjoner og beskrivelser av tegn, symptomer og relaterte faktorer (7,14).…”

Section: Noe For Deg?unclassified

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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The quality of home care nurses’ documentation in new electronic patient records

Abstract: The study contributes to identifying areas of improvement in documentation by nurses in home health care.

Cited by 50 publications

References 29 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

Documentation and communication of nutritional care for elderly hospitalized patients: perspectives of nurses and undergraduate nurses in hospitals and nursing homes

Implementering av sykepleiediagnoser i fritekst

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