scholarly journals Quality of Care: Ecological Study for the Evaluation of Completeness and Accuracy in Nursing Assessment

2020 ◽  
Vol 17 (9) ◽  
pp. 3259
Author(s):  
Angela Iula ◽  
Carola Ialungo ◽  
Chiara de Waure ◽  
Matteo Raponi ◽  
Matteo Burgazzoli ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Nutritional Status ◽  
Pain Assessment ◽  
Negative Influence ◽  
Average Weight ◽  
Nursing Documentation ◽  
Nursing Assessment ◽  
Charge Nurse ◽  
Related Group

Nursing documentation is an important proxy of the quality of care, and quality indicators in nursing assessment can be used to assess and improve the quality of care in health care institutions. The study aims to evaluate the completeness and the accuracy of nursing assessment, analyzing the compilation of pain assessment and nutritional status (body mass index (BMI)) in computerized nursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis related group weight (DRG), seniority of charge nurse, and type of ward (medical, surgical or other). The observational ecological pilot study was conducted between September and October 2018 in an Italian Tertiary-Level Teaching Hospital. The nursing documentation analyzed for the ‘Assessment’ phase included 12,513 records, 50.4% concerning pain assessment, and 45% BMI. The nurse–patient ratio showed a significant direct association with the assessment of nutritional status (p = 0.032). The average weight DRG has a negative influence on pain and BMI assessment; the surgical units positively correlate with the compilation of nursing assessment (BMI and pain). The nursing process is an essential component for the continuous improvement in the quality of care. Nurses need to be accountable to improve their knowledge and skills in nursing documentation.

scholarly journals Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Nataliya Brima ◽  
Nick Sevdalis ◽  
K. Daoh ◽  
B. Deen ◽  
T. B. Kamara ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Quality Of Care ◽  
Sierra Leone ◽  
Referral Hospital ◽  
Audit And Feedback ◽  
Health System Strengthening ◽  
Theory Of Change ◽  
Improve Quality ◽  
Nursing Documentation

Abstract Background There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. Methods This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting. Discussion We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. Trial registration Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

scholarly journals Optimalisasi peran & fungsi manajemen kepala ruangan dalam supervisi dokumentasi asuhan keperawatan di rumah sakit x Jakarta

2021 ◽  
Vol 14 (4) ◽  
pp. 536-544
Author(s):  
Teresa Teresa ◽  
Tuti Afrianti ◽  
Tini Suminarti
Keyword(s):  
Quality Of Care ◽  
Nursing Care ◽  
Health Care Quality ◽  
Descriptive Analysis ◽  
Pilot Project ◽  
Poor Quality ◽  
Care Quality ◽  
Nursing Documentation ◽  
Head Nurse

The role of a head nurse in optimizing of management function in supervision of nursing care documentation at X hospital in JakartaBackground: Nursing documentation is important thing that  is indicator quality of care. Since the nursing documentation is still a poor quality, it requires a supervision by the head nurse.Purpose: The head of nursing is responsible for the direction, organization and strategic planning collaborate with nursing staffs in ensuring the quality of nursing care to achieve accurate, effective and efficient documentation and to complete supervision.Method: A pilot project using questionnaire and observation methods was conducted at difference times on two hospital units in Jakarta.Results: The descriptive analysis results showed that among 18 nurses, 4 nurses believed that nursing documentation is an important, effective and clear way to  ease their job. Hence, supervision is continuity needed to support the improvement of health care quality. The innovative projects will be applied in health care.Conclusion:  Nursing documentation must show continuity and quality of  care nursing under the control and supervision of the head nurse and EMR is used as the instrument for documentation.Keywords :  The role; Head nurse; Management; Supervision; Nursing care; DocumentationPendahuluan: Dokumentasi asuhan keperawatan adalah hal yang penting karena menjadi indikator kualitas perawatan. Penerapan dokumentasi asuhan keperawatan saat ini belum optimal sehingga membutuhkan arahan dan supervisi dari Kepala Ruang/Kepala Unit.Tujuan: Tercapainya supervisi dan keberhasilan pelaksanaan dokumentasi asuhan keperawatan yang komprehensif, berkesinambungan, efektif dan  efisien.Metode: Metode pilot project di salah satu Rumah Sakit di Jakarta dengan pengambilan data melalui  observasi dan kuestioner. Instrumen diujikan pada dua ruangan dalam  waktu yang berbeda.Hasil: Analisis deskripsi pada  sejumlah 18 perawat, 4 orang menyatakan bermanfaat, penting dan mudah dalam penerapannya. Supervisi dilakukan untuk memberikan support terhadap kelangsungan pendokumentasian asuhan keperawatan yang berkesinambungan. Proyek inovasi akan ditindaklanjuti dan diaplikasikan dalam program kerja bidang pelayanan keperawatan.Simpulan: Asuhan keperawatan yang berkualitas memerlukan adanya supervisi. Sarannya penggunaan Instrumen Supervise Dokumentasi Asuhan Keperawatan akan disesuaikan dengan penggunaan pencatatan asuhan keperawatan Elektronic Medical Record/EMR

Management of children in status asthmaticus

1998 ◽  
Vol 18 (1) ◽  
pp. 74-82
Author(s):  
EP Briening
Keyword(s):  
Critical Care ◽  
Quality Of Care ◽  
Side Effects ◽  
Status Asthmaticus ◽  
Critical Care Nurses ◽  
Response To Therapy ◽  
Response To Treatment ◽  
Nursing Assessment ◽  
Respiratory Status

Children admitted to the ICU with status asthmaticus require continuous nursing assessment of respiratory status and monitoring of the response to therapy. Nurses must be aware of the progression of respiratory distress and of the expected response to treatment and the side effects that can occur with each therapy. By assuming a greater responsibility in the care of the child with status asthmaticus, critical care nurses can improve the quality of care for these patients.

scholarly journals ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care?

2016 ◽  
Vol 21 (8) ◽  
pp. 638-648 ◽  
Author(s):  
Liz Charalambous ◽  
Sarah Goldberg
Keyword(s):  
Quality Of Care ◽  
Hospital Admission ◽  
Digital Technology ◽  
Older Patients ◽  
Acute Hospital ◽  
Older Person ◽  
Nursing Documentation ◽  
Framework Approach ◽  
Depth Interviews

Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment (CGA) process which can improve older patients’ outcomes following a hospital admission. Our aim is to understand older person nurses’ experiences of and attitudes to documentation, via semi-structured, in-depth interviews of eight qualified nurses at an acute hospital trust. Interviews were analysed using the framework approach to identify key themes. Three overarching themes were identified: gaps, mishaps and overlaps. Gaps refer to information which was missing, inaccurate or inconsistent; mishaps refer to the consequences of these inaccuracies and inconsistencies; and overlaps refer to the problem of duplications in recording of information. Older person nurses report many inconsistencies, omissions and duplications in their documentation. This has implications for how nursing contributes to the CGA and the quality of care of older patients. New ways must be found to minimise and streamline existing documentation to ensure that records are complete, timely and person-centred. Nurses should be mindful that emerging digital technology systems do not create further problems. Ward nurses need to take greater control of development of documentation.

scholarly journals Informal Payments and Performance in the Health Care Sector: Possible Relationships in a Sub-National Perspective

2020 ◽  
Vol 15 (3) ◽  
pp. 126
Author(s):  
Elisabetta Reginato ◽  
Isabella Fadda ◽  
Paola Paglietti ◽  
Aldo Pavan
Keyword(s):  
Health Care ◽  
Quality Of Care ◽  
Health Status ◽  
Access To Care ◽  
Negative Influence ◽  
Informal Payments ◽  
Regional Health Care ◽  
And Performance ◽  
Petty Corruption

The paper explores the relationship between corruption and performance dimensions of the Italian regional health care systems (RHSs). In Europe, Italy shows the widest sub-national in performance and corruption levels. The research focuses on petty corruption in health care. So-called informal payments are the most common form and were measured using data from the European Quality of Government Index Survey. The performance of Italian RHSs was assessed using key indicators divided into three analytical dimensions: health status; access to care; and quality of care. OECD Health Data was used as source data for health status and access to care. As a proxy for quality of care, the study used avoidable mortality, with data drawn from the Italian National Institute of Statistics (ISTAT). The study formulated a research hypothesises that petty corruption has a negative influence on RHS performance. The findings showed considerable regional differences. The results did not confirm the research hypotheses. However, informal payments did show an adverse effect on renunciations to specialist medical examinations due to costs.

scholarly journals Improving the Quality of Nursing Documentation at A Residential Care Home: A Clinical Audit

2020 ◽  
Author(s):  
Preben Søvik Moldskred ◽  
Anne Kristin Snibsøer ◽  
Birgitte Espehaug
Keyword(s):  
Residential Care ◽  
Clinical Audit ◽  
Care Home ◽  
Patient Records ◽  
Nursing Documentation ◽  
Nursing Assessment ◽  
Residential Care Home ◽  
Nursing Diagnoses ◽  
Quality Of Nursing

Abstract Background: Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice.Methods: A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0 - 3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results: None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95% confidence interval 0.3 - 0.6) for “aims for nursing care” to 1.1 (0.9 - 1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8 - 1.1) for “evaluation/progress reports” to 1.9 (1.5 - 2.2) for “nursing assessment on admission”.Conclusions: A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

scholarly journals Improving the quality of nursing documentation at a residential care home: a clinical audit

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Preben Søvik Moldskred ◽  
Anne Kristin Snibsøer ◽  
Birgitte Espehaug
Keyword(s):  
Residential Care ◽  
Clinical Audit ◽  
Care Home ◽  
Patient Records ◽  
Nursing Documentation ◽  
Nursing Assessment ◽  
Residential Care Home ◽  
Nursing Diagnoses ◽  
Quality Of Nursing

Abstract Background Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice. Methods A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0–3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95 % confidence interval 0.3–0.6) for “aims for nursing care” to 1.1 (0.9–1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8–1.1) for “evaluation/progress reports” to 1.9 (1.5–2.2) for “nursing assessment on admission”. Conclusions A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

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