Documentation of Individualized Patient Care: a qualitative metasynthesis

2005 ◽  
Vol 12 (2) ◽  
pp. 123-132 ◽  
Author(s):  
Oili Kärkkäinen ◽  
Terese Bondas ◽  
Katie Eriksson
Keyword(s):  
Qualitative Research ◽  
Patient Care ◽  
Nursing Care ◽  
Ethical Principles ◽  
Nursing Documentation ◽  
Good Patient ◽  
Accurate Picture ◽  
To Receive

The aim of this study was to increase understanding of how individual patient care and the ethical principles prescribed for nursing care are implemented in nursing documentation. The method used was a metasynthesis of the results of 14 qualitative research reports. The results indicate that individualized patient care is not visible in nurses’ documentation of care. It seems that nurses describe their tasks more frequently than patients’ experiences of their care. The results also show that the structure of nursing documentation and the forms or manner of recording presupposed by the organization may prevent individual recording of patient care. In order to obtain visibility for good patient-centred and ethical nursing care, an effort should be made to influence how the content of nursing care is documented and made an essential part of individual patient care. If the content of this documentation does not give an accurate picture of care, patients’ right to receive good nursing care may not be realized.

scholarly journals Developing Mid-Range Theories for the Maturation of Nursing Care in Colombia

Aquichan ◽  
2021 ◽  
Vol 21 (4) ◽  
pp. 1-12
Author(s):  
Janice Morse
Keyword(s):  
Qualitative Research ◽  
Patient Care ◽  
Nursing Care ◽  
Conceptual Models ◽  
Concept Analysis ◽  
Patient Needs ◽  
Nursing Theory ◽  
Changing Patterns ◽  
The 1960S

Nursing theory has evolved since the 1960s, from conceptual models to concept analysis to mid-range theories. Mid-range theories are developed primarily for qualitative research, to target patient problems, to respond to patient needs, to identify interventions and the changing patterns of patient care. These mid-range theories cluster in various patterns to provide valid, coherent, and significant interventions. Examples of programs that have dramatically impacted our understanding of nursing and patient care are presented. Thus, by developing and implementing the findings of mid-range theories, nursing care matures, and the standards advance.

scholarly journals Entry-instrument used in the patient's evaluation in a post-anaesthetic recovery room: a matter of great concern: care continuity

2008 ◽  
Vol 21 (1) ◽  
pp. 24-31 ◽  
Author(s):  
Elaine Reda ◽  
Aparecida de Cássia Giani Peniche
Keyword(s):  
Patient Care ◽  
Nursing Care ◽  
Recovery Room ◽  
Patient Record ◽  
Efficient Strategy ◽  
Care Continuity ◽  
Post Operative Period ◽  
To Receive ◽  
Shift Change

OBJECTIVE: To know the nurses' evaluation about the continuity of nursing care. METHODS: Fifty-nine nurses from two Hospitals (I and II) were interviewed. The questions addressed the following issues: the difficulties they face to obtain the necessary information to provide patient care in the immediate post-operative period; what is the best strategy to receive information related to this period; and what is their evaluation about the entry-instrument of the post anaesthetic recovery. RESULTS: Difficulties in Hospital I: the instrument was often not included in the patient record and changing shifts over the telephone. Hospital II: incomplete completion of the instrument. Best strategy in Hospital I: entry-instrument associated to the shift change over the telephone. Hospital II: to aggregate the several means of information. Both groups evaluated the entry instrument and reported that it helps in the planning because it is a way to document patient care. They considered the aspects contained in the instrument as important and pertinent. CONCLUSIONS: This instrument consists of an efficient strategy for patient care continuity, in spite of the difficulties described above.

scholarly journals Pengalaman Perawat dalam Penggunaan Rekam Medis Elektronik di Rumah Sakit Panti Rini Yogyakarta

2020 ◽  
Vol 1 (2) ◽  
pp. 141-150
Author(s):  
Ernest Novema Dhamar ◽  
Margareta Hesti Rahayu
Keyword(s):  
Qualitative Research ◽  
Electronic Medical Records ◽  
Nursing Care ◽  
Medical Records ◽  
Sampling Technique ◽  
Nursing Documentation ◽  
Purposive Sampling ◽  
Inpatient Ward

Background: Nursing documentation through electronic medical records is expected to provide convenience for nurses. Purpose: explore nurses' experiences in using electronic medical records. Method: this study was a qualitative research, used purposive sampling technique. The research was conducted at Panti Rini Hospital Yogyakarta and conducted in May 2020 and interviewed 5 nurses and 1 head of the ward in the inpatient ward. Result: this study found 4 themes: 1) the use of electronic medical records to provide convenience, 2) supporting factors for the use of electronic medical partners, 3) obstacles in the use of electronic medical records 4) the expectations of nurses in using electronic medical records. Conclusion: the hospital needs to improve facilities and infrastructure so that the available system is able to accommodate the need for electronic nursing care documentation.

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.

scholarly journals Ethical issues relating to qualitative research

2005 ◽  
Vol 61 (1) ◽  
Author(s):  
J. Jelsma ◽  
S. Clow
Keyword(s):  
Qualitative Research ◽  
Health Research ◽  
Ethical Issues ◽  
Ethical Principles ◽  
Ethical Review ◽  
Paper Briefly ◽  
Ethical Problems ◽  
Scientific Rigour ◽  
Hands On

Qualitative research or naturalistic research has moved from the sidelines into the mainstream of health research and an increasing number of qualitative research proposals are being presented for ethical review Qualitative research presents ethical problems that which are unique to the intensive hands-on paradigm which characterises naturalistic research. This paper briefly outlines the most common methodologies used in this research. The four ethical principles of benevolence, non-maleficence, autonomy and justice will be used as a framework to explore specific ethical issues related to this form of inquiry. The need for scientific rigour will also be explored as research that is scientifically unsound can never be ethical.

Somatoform disorders: A help or hindrance to good patient care?

2004 ◽  
Vol 184 (6) ◽  
pp. 465-467 ◽  
Author(s):  
Michael Sharpe ◽  
Richard Mayou
Keyword(s):  
Primary Care ◽  
Patient Care ◽  
General Practitioners ◽  
Somatoform Disorders ◽  
Somatoform Disorder ◽  
Good Patient ◽  
Specific Category ◽  
Good Patient Care ◽  
Almost All ◽  
Issue Reports

The paper by de Waal and colleagues (2004, this issue) reports on the prevalence of somatoform disorders in Dutch primary care. They found that at least one out of six patients seen by general practitioners could be regarded as having a somatoform disorder, almost all in the non-specific category of undifferentiated somatoform disorder. The prevalence of the condition has major implications for medical services but what does this diagnosis mean? Is receiving a diagnosis of somatoform disorder of any benefit to the patient? Does it help the doctor to provide treatment?

The Effect of Nocturnal Patient Care Interventions on Patient Sleep and Satisfaction With Nursing Care in Neurosurgery Intensive Care Unit

2015 ◽  
Vol 47 (2) ◽  
pp. 104-112 ◽  
Author(s):  
Gülay Altun Uğraş ◽  
Sultan Babayigit ◽  
Keziban Tosun ◽  
Güler Aksoy ◽  
Yüksel Turan
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Patient Care ◽  
Nursing Care

scholarly journals Nursing care in the anesthetic procedure: an integrative review

2016 ◽  
Vol 50 (1) ◽  
pp. 154-162 ◽  
Author(s):  
Cassiane de Santana Lemos ◽  
Aparecida de Cassia Giani Peniche
Keyword(s):  
United States ◽  
Health System ◽  
Patient Care ◽  
Nursing Care ◽  
Scientific Evidence ◽  
The United States ◽  
Nurse Anesthetists ◽  
Integrative Review ◽  
Nursing Professional

Abstract OBJECTIVE To search for the scientific evidence available on nursing professional actions during the anesthetic procedure. METHOD An integrative review of articles in Portuguese, English and Spanish, indexed in MEDLINE/PubMed, CINAHL, LILACS, National Cochrane, SciELO databases and the VHL portal. RESULTS Seven studies were analyzed, showing nurse anesthetists' work in countries such as the United States and parts of Europe, with the formulation of a plan for anesthesia and patient care regarding the verification of materials and intraoperative controls. The barriers to their performance involved working in conjunction with or supervised by anesthesiologists, the lack of government guidelines and policies for the legal exercise of the profession, and the conflict between nursing and the health system for maintenance of the performance in places with legislation and defined protocols for the specialty. Conclusion Despite the methodological weaknesses found, the studies indicated a wide diversity of nursing work. Furthermore, in countries absent of the specialty, like Brazil, the need to develop guidelines for care during the anesthetic procedure was observed.

Description of good patient care at the end of life

2016 ◽  
Vol 32 ◽  
pp. 245-246 ◽  
Author(s):  
Sanghee Kim ◽  
Minjeong Seo
Keyword(s):  
Patient Care ◽  
End Of Life ◽  
Good Patient ◽  
Good Patient Care
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