scholarly journals Development and evaluation of an electronic nursing documentation system

BMC Nursing ◽  
2022 ◽  
Vol 21 (1) ◽  
Author(s):  
Mohsen Shafiee ◽  
Mostafa Shanbehzadeh ◽  
Zeinab Nassari ◽  
Hadi Kazemi-Arpanahi
Keyword(s):  
Literature Review ◽  
Patient Care ◽  
Nursing Care ◽  
Delphi Study ◽  
Methodological Approach ◽  
Care Practice ◽  
Nursing Documentation ◽  
Documentation System ◽  
Data Set ◽  
Care Plans

Abstract Background Nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context. Methods A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users. Results The proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system. Conclusions The developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.

scholarly journals Development and Evaluation of an Electronic Nursing Documentation System

2021 ◽  
Author(s):  
Mohsen Shafiee ◽  
Mostafa Shanbehzadeh ◽  
Zeinab Nassari ◽  
Hadi Kazemi-Arpanahi
Keyword(s):  
Literature Review ◽  
Patient Care ◽  
Nursing Care ◽  
Delphi Study ◽  
Methodological Approach ◽  
Care Practice ◽  
Nursing Documentation ◽  
Documentation System ◽  
Data Set ◽  
Care Plans

Abstract Introduction: nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reporting is described in scientific literature and care practice, and no uniform structured documentation is given. Aims This study aimed to describe the process of designing and evaluating the content of an electronic nursing documentation system to provide consistent and unified reporting in this context. Methods A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisting of two phases, as follows: A literature review was performed to attain an exhaustive overview of relevant elements of nursing and map the available evidence underpinning the development of the MDS. Second, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Next, the electronic nursing system (ENS) was developed according to the finalized MDS, and finally, its performance was evaluated by involved the end-users. Results The proposed MDS was divided into administrative and clinical sections; including nursing assessment and nursing diagnosis process. Then, a web-based system with modular and layered architecture was designed based on derived MDS. Finally, to evaluate it, a survey by participating 150 registered nurses (RNs) was conducted and the positive impacts and negative impacts of the system were identified. Conclusion The developed system is suitable for the documentation of patient care in nursing care plans. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.

Nursing Care Plans: Guidelines for Planning Patient Care

AORN Journal ◽  
1989 ◽  
Vol 50 (6) ◽  
pp. 1326
Author(s):  
Juliette Hennessy
Keyword(s):  
Patient Care ◽  
Nursing Care ◽  
Care Plans

scholarly journals Digital Documentation Platforms in Prehospital Care- Do They Support the Nursing Care

2019 ◽  
Vol 8 (1) ◽  
pp. 84
Author(s):  
Torbjörn Pahlin ◽  
Janet Mattsson
Keyword(s):  
Patient Safety ◽  
Nursing Care ◽  
Technological Development ◽  
Prehospital Care ◽  
Ambulance Service ◽  
Nursing Documentation ◽  
Documentation System ◽  
Transport Organization ◽  
Life Threatening ◽  
Group Interviews

This study examines and describe the ambulance nurse's experience of nursing documentation in single responder and the transfer of the documentation to other care levels.  A qualitative design was used with focus group interviews as data collection method to enhance knowledge of the everyday experience of nursing documentation. The ambulance service in Sweden is a profession in transition that evolved from being a transport organization to provide advanced medical care and nursing. However, all patients do not need advanced medical treatment and the Single responder is an alternative resource to the ambulance that is used when no life-threatening conditions exists. However, the nurse faces a number of challenges when documenting nursing care interventions related to technological development and the mismatch between the care offered and people's demands and needs. Even though nursing care documentation is key to enhance and develop patient safety within a young field as ambulance service. There is a lack of a coherent documentation system and two themes emerged through content analyzes which conveyed how nursing care becomes invisible and how nursing care interventions are communicated through a hidden language. There are serious shortcomings in the transfer of nursing documentation to other care levels as well as deficiencies in the nursing documentation. Which jeopardizes the quality of care and patient safety as well as a systematic development of nursing care in this field.  

Documenting and communicating patient care: Are nursing care plans redundant?

2000 ◽  
Vol 6 (5) ◽  
pp. 276-280 ◽  
Author(s):  
Bev O'connell Rn ◽  
Helen Myers Rn ◽  
Di Twigg Rn ◽  
Fiona Entriken Rn
Keyword(s):  
Patient Care ◽  
Nursing Care ◽  
Care Plans

Current and Future Use of ICT for Patient Care and Management in German Acute Hospitals

2005 ◽  
Vol 44 (04) ◽  
pp. 528-536 ◽  
Author(s):  
B. Sellemann ◽  
U. Hübner
Keyword(s):  
Patient Care ◽  
Clinical Applications ◽  
Current Status ◽  
Nursing Documentation ◽  
Documentation System ◽  
Hospital Managers ◽  
Nursing Managers ◽  
Acute Hospitals ◽  
Nation Wide Survey ◽  
Ordering Systems

Summary Objectives: This study aimed at gaining comprehensive information on the current status of patient care and management applications used in German acute hospitals. Since the degree of ICT coverage in hospitals depends on the attitude of the key decision makers we also wanted to capture their plans and priorities and herewith try to predict future use. Methods: We therefore conducted a nation-wide survey including all acute hospitals in Germany in which two questionnaires were mailed to each hospital, one to the nursing managers, the other to the hospital managers. Results: Six hundred hospitals participated in the survey which corresponds to an overall response rate of 27.6%. Accounting (84%) was found to be the most prevalent management module. Rostering was implemented in every second hospital. For clinical applications laboratory systems ranked first (69%). Ordering systems were used in nearly every second hospital. Nineteen percent of the hospitals reported employing an electronic patient record, 7% a nursing documentation system. Ranked by their priorities ordering systems hold the first position and care planning the last position. According to their plans, hospital managers, not nursing managers, intend to introduce nursing documentation. In contrast, nursing managers favor ordering and rostering for the near future. Conclusions: There is still a preponderance of management-oriented systems in German hospitals, yet clinical applications, in particular those supporting communications, will gain ground. The future of documentation systems is unclear, unless they not only provide statistical data for the management but support the clinical process properly.

scholarly journals Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature

2020 ◽  
Vol 14 (1) ◽  
pp. 17-28
Author(s):  
Tomy Suganda ◽  
Rr Tutik Sri Hariyati
Keyword(s):  
Literature Review ◽  
Nursing Care ◽  
Strong Support ◽  
Cost Effective ◽  
Scientific Publication ◽  
Nursing Documentation ◽  
Health Records ◽  
Technological Developments ◽  
Paper Documentation

Paper‐based versus electronic‐based of health records in quality of nursing documentation: A literature review study.Background: Many technological developments in nursing services have emerged, one of them is electronic-based nursing documentation. The electronic nursing documentation has a good impact which increases the quality of service. But the readiness is still questionable.Purpose: Describing the quality comparison of electronic-based nursing documentation and paper-based nursing documentation.Method: This study uses a PRISMA literature review. Through the remote-lib.ui.ac.id database that is connected to various scientific publication pages such as, Scopus, Ebsco, PROQUEST Scholar-Articles with several key words such as electronic nursing documentation, nursing paper documentation, management information systems.Results: Electronic-based documentation has a higher level of quality documentation than paper-based documentation in terms of efficiency, effectiveness, patient focus and timeliness.Conclusion: Electronic-based documentation offers the optimization of nursing care, effective and efficient documentation, integrated nursing care and cost-effective through (paperless). Strong support from hospital institutions, organizations and government at the beginning of the nurse adaptation system and process is a challenge so that the application of electronic nursing documentation is realized properly.Keywords: Paper‐based; Electronic‐based; Health records; Quality; Nursing documentation.Pendahuluan: Pengembangan teknologi dalam pelayanan keperawatan banyak bermunculan, salah satunya dokumentasi keperawatan berbasis elektronik. Dokumentasi keperawatan elektronik memberikan dampak baik yang luarannya meningkatkan kualitas pelayanan. Namun kesiapan masih dipertanyakan.Tujuan: Menggambarkan perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan dokumentasi keperawatan berbasis kertas.Metode: Penelitian ini menggunakan tinjauan pustaka PRISMA. Melalui Database remote-lib.ui.ac.id yang terhubung dengan berbagai macam laman publikasi ilmiah seperti, Scopus, Ebsco, PROQUEST, Scholar-Artikel dengan beberapa kata kunci seperti dokumentasi keperawatan elektronik, dokumentasi keperawatan kertas, sistem informasi manajemen.Hasil: Dokumentasi berbasis elektronik memiliki tingkat kualitas dokumentasi lebih dibandingkan dokumentasi berbasis kertas secara efesiensi, efektifitas, fokus pada pasien maupun ketepatan waktu.Simpulan: Dokumentasi berbasis elektronik menawarkan keoptimalan melakukan asuhan keperawatan, dokumentasi efektif dan efesien, asuhan keperawatan terintegrasi serta cost-effective melalui (paperless). Dukungan kuat dari institusi rumah sakit, organisasi maupun pemerintah dalam permulaan sistem dan proses adaptasi perawat menjadi tantangan, agar penerapan dokumentasi keperawatan elektronik terealisasi dengan baik.

scholarly journals Analisis Sistim Manajemen Dokumentasi Keperawatan pada Poliklinik Gigi Rumah Sakit di Bukittinggi

2015 ◽  
Vol 4 (3) ◽  
Author(s):  
Dewi Rosmalia ◽  
Rizanda Machmud ◽  
Haryadi Mangkuto
Keyword(s):  
Nursing Care ◽  
Nursing Staff ◽  
Analysis Data ◽  
Dental Clinic ◽  
Nursing Documentation ◽  
Documentation System ◽  
Head Nurse ◽  
Clinic Management ◽  
Dynamic Coordination ◽  
Dental Hospital

Abstrak Dokumentasi keperawatan merupakan bukti tertulis pelayanan yang diberikan kepada pasien oleh tenaga keperawatan yang bertujuan untuk menghindari kesalahan, tumpang tindih dan ketidak lengkapan informasi. Dalam asuhan keperawatan agar terbinanya koordinasi yang baik dan dinamis antar tenaga keperawatan serta meningkatkan efisiensi, efektifitas dan menjamin kualitas asuhan keperawatan. Tujuan penelitian ini adalah  menganalisis sistim manajemen dokumentasi keperawatan pada poliklinik gigi rumah sakit berdasarkan standar pelayanan keperawatan. Penelitian dilakukan dengan metode analisis kualitatif, sumber data berasal dari observasi, dokumen dan wawancaramendalam. Informan penelitian berjumlah 10 (sepuluh) orang yang terdiri dari direktur rumah sakit, ketua PPGI Kota Bukittinggi, kepala ruangan poliklinik gigi/ kepala instalasi dan perawat gigi di pol iklinik gigi rumah sakit di Bukittinggi. Validasi data dilakukan dengan triangulasi, selanjutnya dilakukan analisis data, reduksi data, interpretasi dankomunikasikan makna temuan melalui laporan tertulis. Hasil penelitian didapatkan dokumentasi keperawatan pada poliklinik gigi belum terlaksana dengan optimal, hal ini mempengaruhi proses pendokumentasian, tidak tersedianya kartu khusus pencatatan pemeriksaan dan perawatan gigi juga sangat mempengaruhi sistim dokumentasi keperawatan pada poliklinik gigi. Kesimpulan penelitian ini ialahsistim penyelenggaraan dokumentasi keperawatanpada poliklinik gigi belum terlaksana dengan optimal karena belum tersedianya kartu pencatatan pemeriksaan dan perawatan gigi pada poliklinik gigi rumah sakit, belum adanya SOP dokumentasi keperawatan dan jika ada tidak pernah disosialisasikan. Kata kunci: dokumentasi, poliklinik gigi, manajemenAbstract Nursing documentation is written proof of service to patients by nursing staff that aims to avoid errors, and incompleteness of information overlapping in nursing so good and dynamic coordination between nursing staff and improve the efficiency, effectiveness and ensure the quality of nursing care. The objective of this study was to analyze nursing documentation management system in a hospital dental clinic based nursing care standards. The study was conducted with qualitative analysis methods, data sources derived from observations, documents and in-depth interviews. Informants numbered 10 ( ten ) members consisting of the hospital director, chief dental nurses union Indonesia ( PPGI ) of Bukittinggi, the head of the room / installation and head nurse at the dental clinic dental hospital in Bukittinggi. Data validation is done by triangulation, then performed the data analysis, data reduction, data display and conclusion. The results showed nursing documentation in the dental clinic has not done optimally, this affects the process of documenting, recording card unavailability of dental examinations and treatment also greatly affect the nursing documentation system in the dental clinic. In conclusion, the implementation of a nursing documentation system at a dental clinic is not performing optimally due to the unavailability of recording card dental examinations and treatment at the hospital dental clinic, lack of standard operating procedures (SOP) nursing documentation. Keywords: documentation, dental clinic, management

scholarly journals Metode Pendokumentasian Elektronik dalam Meningkatkan Kualitas Pelayanan Keperawatan

2018 ◽  
Vol 9 (3) ◽  
pp. 497
Author(s):  
Sulastri Sulastri ◽  
Niken Yuniar Sari
Keyword(s):  
Nursing Care ◽  
Information Exchange ◽  
Nursing Documentation ◽  
Documentation System ◽  
Care Services ◽  
Client Data ◽  
Technological Developments ◽  
Modern Era ◽  
Nursing Processes

Nursing documentation is one of the most important functions for nurses in providing nursing care. The nursing process in the modern era is now a demand from various aspects for nurses. The current development is that nurses must carry out nursing processes based on nursing care standards. The use of electronic nursing documentation can always evolve in line with technological developments, this can increase client life expectancy and reduce errors in intervening with clients. This IT-based documentation system will help in meeting documentation standards, can improve the quality of documentation, facilitate decision making and provide information that is easy to access, can minimize the potential for loss or damage to development records, improve information exchange and coordination between nurses or other health teams, documentation can be easily audited, help improve the accuracy of client data, can access the progress of client health development and reduce maintenance costs so that it can improve the quality of care services.

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