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263 records – page 1 of 27.

Accuracy and quality in the nursing documentation of pressure ulcers: a comparison of record content and patient examination.

https://arctichealth.org/en/permalink/ahliterature77064
Source
J Wound Ostomy Continence Nurs. 2004 Nov-Dec;31(6):328-35
Publication Type
Article
Author
Gunningberg Lena
Ehrenberg Anna
Author Affiliation
Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden. lena.gunningberg@akademiska.se
Source
J Wound Ostomy Continence Nurs. 2004 Nov-Dec;31(6):328-35
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Cross-Sectional Studies
Documentation - standards
Female
Health services needs and demand
Hospitals, University
Humans
Male
Middle Aged
Nursing Assessment - standards
Nursing Audit
Nursing Evaluation Research
Nursing Records - standards
Observer Variation
Physical Examination - nursing - standards
Practice Guidelines
Pressure Ulcer - diagnosis - epidemiology - nursing
Prevalence
Retrospective Studies
Risk assessment
Severity of Illness Index
Sweden - epidemiology
Abstract
OBJECTIVE: To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting. DESIGN: A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients. SETTING AND SUBJECTS: All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital. INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation. METHODS: All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments. RESULTS: The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor. CONCLUSIONS: Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.
PubMed ID
15867708 View in PubMed
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The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions.

https://arctichealth.org/en/permalink/ahliterature71494
Source
Scand J Caring Sci. 2001;15(4):303-10
Publication Type
Article
Date
2001
Author
A. Ehrenberg
M. Ehnfors
Author Affiliation
Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. aeh@du.se
Source
Scand J Caring Sci. 2001;15(4):303-10
Date
2001
Language
English
Publication Type
Article
Keywords
Aged - psychology
Aged, 80 and over
Attitude of Health Personnel
Attitude to Health
Comparative Study
Education, Nursing, Continuing - standards
Female
Geriatric Assessment
Homes for the Aged
Humans
Inservice Training - standards
Male
Nursing Assessment - standards
Nursing Audit
Nursing Education Research
Nursing Evaluation Research
Nursing Homes
Nursing Process - standards
Nursing Records - standards
Nursing Staff - education - psychology
Questionnaires
Research Support, Non-U.S. Gov't
Sweden
Abstract
The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions. Data from patient records will increasingly be used for care planning, quality assessment, research, health planning and allocation of resources. Knowledge about the accuracy of such secondary data, however, is limited and only a few studies have been conducted on the accuracy of nursing recording. The aim of this study was to analyse the concordance between the nursing documentation in nursing homes and descriptions of some specific problems of nurses and patients. Comparisons were made between wards where nurses had received training in structured recording based on the nursing process (study group) and wards where no intervention had taken place (reference group). Data were collected from the patient records of randomly selected nursing home residents (n=85). The methods used were audits of patient records and structured interviews with residents and nurses. The study revealed considerable deficiencies in the accuracy of the patient records when the records were compared with the reports from nurses and residents. The overall agreement between the interview data from nurses and from the patient records was low. Concordance was better in the study group as compared with the reference group in which the recorded data were structured only following chronological order. The study unequivocally demonstrates that there are major limitations in using records as a data source for the evaluation, planning and development of care.
PubMed ID
12453171 View in PubMed
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The Aggression Observation Short Form identified episodes not reported on the Staff Observation Aggression Scale--Revised.

https://arctichealth.org/en/permalink/ahliterature266542
Source
Issues Ment Health Nurs. 2014 Jun;35(6):464-9
Publication Type
Article
Date
Jun-2014
Author
Jacob Hvidhjelm
Dorte Sestoft
Jakob Bue Bjørner
Source
Issues Ment Health Nurs. 2014 Jun;35(6):464-9
Date
Jun-2014
Language
English
Publication Type
Article
Keywords
Adult
Aggression - psychology
Cross-Sectional Studies
Data Collection - statistics & numerical data
Denmark
Female
Humans
Male
Mental Disorders - epidemiology - nursing
Middle Aged
Nursing Records - statistics & numerical data
Observation
Psychiatric Department, Hospital
Risk Management
Violence - psychology - statistics & numerical data
Young Adult
Abstract
The purpose of this study is to evaluate the underreporting of violence and aggression on the Staff Observation Aggression Scale-Revised (SOAS-R) when compared to a simpler assessment: the Aggression Observation Short Form (AOS). During a period of one year, two open and two closed wards gathered data on both the SOAS-R and the AOS for all of their patients. The 22-item SOAS-R is to be filled out after each violent episode. The 3-item AOS is to be filled out during each shift and should also record the absence of violence. The SOAS-R registered 703 incidents and the AOS registered 1,281 incidents. The agreement between the SOAS-R and the AOS was good (kappa = 0.65, 95% CI = 0.62-0.67). Among the 1,281 AOS episodes, 51% were also registered on the SOAS-R. For the 176 AOS episodes with harm, 42% were also registered on the SOAS-R. We found 44% missing registrations on the AOS, primarily for open wards and for patients with short admission lengths. Standard instruments such as the SOAS-R underreport aggressive episodes by 45% or more. Underreporting can be reduced by introducing shorter instruments, but it cannot be completely eliminated.
PubMed ID
24857530 View in PubMed
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Agreement in documentation of symptoms, clinical signs, and treatment at the end of life: a comparison of data retrieved from nurse interviews and electronic patient records using the Resident Assessment Instrument for Palliative Care.

https://arctichealth.org/en/permalink/ahliterature130221
Source
J Clin Nurs. 2012 May;21(9-10):1416-24
Publication Type
Article
Date
May-2012
Author
Simen A Steindal
Liv Wergeland Sørbye
Inger Schou Bredal
Anners Lerdal
Author Affiliation
Diakonhjemmet University College, Institute of Nursing and Health, Oslo, Norway. Steindal@diakonhjemmet.no
Source
J Clin Nurs. 2012 May;21(9-10):1416-24
Date
May-2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Cross-Sectional Studies
Female
Humans
Interviews as Topic
Male
Medical Records Systems, Computerized
Middle Aged
Norway
Nursing Records
Palliative Care
Terminal Care
Abstract
To assess agreement between data retrieved from interviews with nurses and data from electronic patient records (EPR) about hospitalised patients' symptoms, clinical signs and treatment during the last three days of life.
Patient records have been used to map symptom prevalence in dying hospitalised patients. However, deficiencies have been found regarding nursing documentation. To our knowledge, this is the first study to assess the agreement between nurse interviews and patient electronic records during the last three days of life in a hospital.
This retrospective study was undertaken in a Norwegian hospital.
We used the resident assessment instrument for palliative care to interview nurses on 112 dying patients, and we independently extracted data from EPR. The agreement between the two data sets was computed with the kappa coefficient. Sensitivity and specificity were calculated. Interview data were used as a reference.
The agreement between the two data sets ranged from poor to good and was highest among symptom variables, including pain, dyspnoea, nausea and the clinical sign falls. In contrast, several clinical variables ranged from poor to fair levels of agreement. The majority of the treatment variables ranged from moderate to good levels of agreement.
Data from the EPR on symptoms (e.g., pain, dyspnoea and nausea) and treatment variables appeared to be reliable and trustworthy, but the data related to fatigue, dry mouth, bloating and sleep interfering with normal functioning should be interpreted carefully.
This study contributed to knowledge of agreement between data from nurse interviews and electronic records on symptoms, clinical signs and treatment of dying patients in last three days of life.
PubMed ID
22023535 View in PubMed
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An educational intervention for district nurses: use of electronic records in leg ulcer management.

https://arctichealth.org/en/permalink/ahliterature78585
Source
J Wound Care. 2007 Jan;16(1):29-32
Publication Type
Article
Date
Jan-2007
Author
Lagerin A.
Nilsson G.
Törnkvist L.
Author Affiliation
Karolinska Institute, Centre for Family and Community Medicine (CeFAM), Huddinge, Sweden. Annica.Lagerin@sll.se
Source
J Wound Care. 2007 Jan;16(1):29-32
Date
Jan-2007
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Clinical Competence - standards
Data Collection - methods
Documentation
Education, Nursing, Continuing - organization & administration
Female
Humans
Inservice Training - organization & administration
Leg Ulcer - nursing - ultrasonography
Male
Medical Records Systems, Computerized - utilization
Middle Aged
Nursing Assessment - methods
Nursing Audit - methods
Nursing Education Research - methods
Nursing Evaluation Research - methods
Nursing Records
Program Evaluation
Public Health Nursing - education - organization & administration
Skin Care - nursing
Sweden
Abstract
OBJECTIVE: To evaluate district nurses' management of leg ulcer patients and the effects of an in-service education programme led by district nurses as local educators at primary health-care centres. METHOD: Data were collected from electronic patient records (EPRs), both before and after the educational intervention. Nineteen district nurses undertook a one-day course focusing on four themes: Doppler assessment and measurement of ankle brachial pressure index; compression treatment; patient education; nursing documentation. Fourteen acted as in-service educators; 12 educators completed the intervention.The EPRs were scrutinised with an audit tool. RESULTS: The documentation on the selected key areas for the management of patients with leg ulcers was generally sparse, although the educational intervention resulted in statistically significant effects on documentation in three areas. CONCLUSION: Further improvements in care are necessary, as are qualitative and quantitative studies to explore the large discrepancies between guidelines and everyday clinical practice in this field.
PubMed ID
17334143 View in PubMed
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Applicability of the Nursing Interventions Classification to describe nursing.

https://arctichealth.org/en/permalink/ahliterature174926
Source
Scand J Caring Sci. 2005 Jun;19(2):128-39
Publication Type
Article
Date
Jun-2005
Author
Asta Thoroddsen
Author Affiliation
Faculty of Nursing, University of Iceland and Landspitali University Hospital, Reykjavik, Iceland. astat@hi.is
Source
Scand J Caring Sci. 2005 Jun;19(2):128-39
Date
Jun-2005
Language
English
Publication Type
Article
Keywords
Adult
Aged
Analysis of Variance
Attitude of Health Personnel
Factor Analysis, Statistical
Health Knowledge, Attitudes, Practice
Health services needs and demand
Humans
Iceland
Medical Records Systems, Computerized
Middle Aged
Nurse's Role
Nursing Evaluation Research
Nursing Informatics
Nursing Methodology Research
Nursing Process - classification
Nursing Records
Nursing Staff - education - psychology
Questionnaires
Semantics
Sensitivity and specificity
Terminology as Topic
Translating
Vocabulary, Controlled
Abstract
The aim of this survey was to test the applicability of the Nursing Interventions Classification (NIC) system for use in a future nursing information system for documenting nursing in an electronic patient record in Iceland. Also, the aim was to test the translation of NIC into Icelandic. In order to be applicable to nursing NIC needs to be sensitive enough to describe the work nurses do, differentiate between specialities in nursing, and be understandable to nurses. A sample of 198 nurses was asked to identify how often they used each of 433 NIC nursing interventions. Of the 36 most frequently used interventions half are within the physiological domain. Core nursing interventions were different between specialities, e.g. Analgesic Administration had a high mean score in surgical nursing, and Health Education in primary health care. anova for the 27 classes in NIC showed significant differences (p
PubMed ID
15877638 View in PubMed
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Assessment and documentation of patients' nutritional status: perceptions of registered nurses and their chief nurses.

https://arctichealth.org/en/permalink/ahliterature93100
Source
J Clin Nurs. 2008 Aug;17(16):2125-36
Publication Type
Article
Date
Aug-2008
Author
Persenius Mona Wentzel
Hall-Lord Marie-Louise
Bååth Carina
Larsson Bodil Wilde
Author Affiliation
Department of Nursing, Karlstad University, Karlstad, Sweden. mona.persenius@kau.se
Source
J Clin Nurs. 2008 Aug;17(16):2125-36
Date
Aug-2008
Language
English
Publication Type
Article
Keywords
Adult
Attitude of Health Personnel
Chi-Square Distribution
Documentation - standards
Guideline Adherence - standards
Health Knowledge, Attitudes, Practice
Humans
Logistic Models
Malnutrition - diagnosis - epidemiology
Mass Screening
Middle Aged
Models, Nursing
Nurse Administrators - psychology
Nurse's Role
Nursing Assessment - standards
Nursing Evaluation Research
Nursing Methodology Research
Nursing Records - standards
Nursing Staff - education - organization & administration - psychology
Nutrition Assessment
Nutritional Status
Practice Guidelines as Topic
Questionnaires
Statistics, nonparametric
Sweden - epidemiology
Abstract
AIMS: To study, within municipal care and county council care, (1) chief nurses' and registered nurses' perceptions of patient nutritional status assessment and nutritional assessment/screening tools, (2) registered nurses' perceptions of documentation in relation to nutrition and advantages and disadvantages with a documentation model. BACKGROUND: Chief nurses and registered nurses have a responsibility to identify malnourished patients and those at risk of malnutrition. DESIGN AND METHODS: In this descriptive study, 15 chief nurses in municipal care and 27 chief nurses in county council care were interviewed by telephone via a semi-structured interview guide. One hundred and thirty-one registered nurses (response rate 72%) from 14 municipalities and 28 hospital wards responded to the questionnaire, all in one county. RESULTS: According to the majority of chief nurses and registered nurses, only certain patients were assessed, on admission and/or during the stay. Nutritional assessment/screening tools and nutritional guidelines were seldom used. Most of the registered nurses documented nausea/vomiting, ability to eat and drink, diarrhoea and difficulties in chewing and swallowing, while energy intake and body mass index were rarely documented. However, the majority documented their judgement about the patient's nutritional condition. The registered nurses perceived the VIPS model (Swedish nursing documentation model) as a guideline as well as a model obstructing the information exchange. Differences were found between nurses (chief nurses/registered nurses) in municipal care and county council care, but not between registered nurses and their chief nurses. CONCLUSIONS: All patients are not nutritionally assessed and important nutritional parameters are not documented. Nutritionally compromised patients may remain unidentified and not properly cared for. RELEVANCE TO CLINICAL PRACTICE: Assessment and documentation of the patients' nutritional status should be routinely performed in a more structured way in both municipal care and county council care. There is a need for increased nutritional nursing knowledge.
PubMed ID
18510576 View in PubMed
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Assessment and intervention for ischemic chest pain: a case study with legal implications for nursing practice.

https://arctichealth.org/en/permalink/ahliterature213314
Source
Prog Cardiovasc Nurs. 1996;11(3):17-22
Publication Type
Article
Date
1996
Author
S P Small
Author Affiliation
School of Nursing, Memorial University of Newfoundland, St. John's, Canada.
Source
Prog Cardiovasc Nurs. 1996;11(3):17-22
Date
1996
Language
English
Publication Type
Article
Keywords
Adult
Canada
Disabled Persons
Electrocardiography
Humans
Male
Malpractice - legislation & jurisprudence
Myocardial Infarction - diagnosis - nursing
Nursing Assessment - legislation & jurisprudence - standards
Nursing Records - legislation & jurisprudence
Abstract
In order to reduce early and long-term mortality and morbidity from myocardial infarction, nurses must promptly and thoroughly assess chest pain, intervene quickly and evaluate the results of the interventions. In Kielley v. General Hospital Corp. et al, a patient suffered a massive heart attack while under observation on a cardiology unit. The court held the hospital liable for the nurses' breach of its chest pain protocol and for failing to have electrocardiograms done when the patient experienced pain. The case clearly illustrates the harm a patient may incur when nurses fail to properly assess and intervene. It reinforces the importance of adherence to hospital protocols that have been put in place to ensure patient safety.
PubMed ID
8878296 View in PubMed
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263 records – page 1 of 27.