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.  

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.

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 EFFECT OF NANDA-I, NIC, AND NOC DOCUMENTATION SYSTEM TRAINING ON QUALITY OF NURSING CARE DOCUMENTATION IN THE PERINATAL WARD OF YOGYAKARTA REGIONAL PUBLIC HOSPITAL

2019 ◽  
Vol 5 (5) ◽  
pp. 180-191
Author(s):  
Enny Eko Setyaningrum ◽  
Intansari Nurjannah ◽  
Anik Rustiyaningsih
Keyword(s):  
Nursing Care ◽  
Public Hospital ◽  
Nursing Intervention ◽  
Control Group ◽  
Nursing Documentation ◽  
Documentation System ◽  
Significant Difference ◽  
Before And After ◽  
Quality Of Nursing

Background: The existing standard of nursing language consists of NANDA-I for diagnostic language standard, Nursing Intervention Classification (NIC) for nursing intervention, and Nursing Outcome Classification (NOC) for nursing outcomes. One way to improve the quality of nursing care documentation is to provide training in the documentation system.Objectives: To determine the effect of providing NANDA-I, NIC, and NOC (NNN) nursing care documentation systems training on the quality of nursing documentation.Methods: This was a pre-experimental study with pretest posttest design without a control group.  Twenty-one nurses and eighty-six Medical Records (MR) of patients who were treated in the perinatal ward of Yogyakarta Regional Public Hospital were used as samples selected using purposive sampling. Those nurses were trained in the nursing care documentation system. The quality of nursing care documentation was measured using modified Quality of Diagnoses, Interventions and Outcomes (Q-DIO) instrument. Data were analyzed using Independent samples t-test with a confidence level of 95%.Results: The average of the scores of the quality of nursing documentation before training was lower (1.91) than the average after training (2.78). There was a significant difference in the quality of nursing documentation before and after training (p < 0.001).Conclusion: Training of NNN nursing documentation system could improve the quality of nursing documentation in the perinatal ward of Yogyakarta Regional Public Hospital.

scholarly journals Spiritual nursing care: A concept analysis

Curationis ◽  
2012 ◽  
Vol 35 (1) ◽  
Author(s):  
Lydia V. Monareng
Keyword(s):  
Nursing Care ◽  
Concept Analysis ◽  
Operational Definition ◽  
The Body ◽  
Empirical Literature ◽  
Spiritual Needs ◽  
Optimal Care ◽  
Health Crisis ◽  
Group Interviews ◽  
Definition Of

Although the concept ‘spiritual nursing care’ has its roots in the history of the nursing profession, many nurses in practice have difficulty integrating the concept into practice. There is an ongoing debate in the empirical literature about its definition, clarity and application in nursing practice. The study aimed to develop an operational definition of the concept and its application in clinical practice. A qualitative study was conducted to explore and describe how professional nurses render spiritual nursing care. A purposive sampling method was used to recruit the sample. Individual and focus group interviews were audio-taped and transcribed verbatim. Trustworthiness was ensured through strategies of truth value, applicability, consistency and neutrality. Data were analysed using the NUD*IST power version 4 software, constant comparison, open, axial and selective coding. Tech’s eight steps of analysis were also used, which led to the emergence of themes, categories and sub-categories. Concept analysis was conducted through a comprehensive literature review and as a result ‘caring presence’ was identified as the core variable from which all the other characteristics of spiritual nursing care arise. An operational definition of spiritual nursing care based on the findings was that humane care is demonstrated by showing caring presence, respect and concern for meeting the needs not only of the body and mind of patients, but also their spiritual needs of hope and meaning in the midst of health crisis, which demand equal attention for optimal care from both religious and nonreligious nurses.

Understanding Patient Safety and Quality Outcome Data

2018 ◽  
Vol 38 (6) ◽  
pp. 58-66 ◽  
Author(s):  
Kathy Easter ◽  
Linda M. Tamburri
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Nursing Care ◽  
Outcome Data ◽  
Regulatory Agencies ◽  
Health Care Outcomes ◽  
Care Outcomes ◽  
Data Transparency

The need for nurses to understand patient safety and quality outcome data is pressing in the current era of data transparency. Health care outcomes data are now publicly reported and readily accessible to consumers, are necessary for performance-based reimbursement, and are required by government and regulatory agencies. In order for nurses at all levels of practice to own their outcomes and be accountable for making improvements, they must possess skills in collecting, analyzing, evaluating, and acting on outcome data. This article provides basic tools and clinical examples for nurses to use in a focused application of outcome data and a structured process for improving nursing care outcomes.

scholarly journals HUBUNGAN INTENSI DENGAN PERILAKU PERAWAT DALAM PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI INSTALASI GAWAT DARURAT

2018 ◽  
Vol 4 (1) ◽  
Author(s):  
Ardhiles Wahyu Kurniawan
Keyword(s):  
Health Care ◽  
Work Environment ◽  
Nursing Care ◽  
Care Process ◽  
Nursing Documentation ◽  
Exclusion Criteria ◽  
Cross Sectional ◽  
Good Intention ◽  
Care Health

Abstract : The complex IGD work environment will affect the quality of care, health care, including inaccurate or incomplete documentation. Incomplete nursing documentation indicates that the nursing care process is not working properly and continuously. Intentionin documenting can predict the appearance of person behavior including the behavior of nurses, especially in documenting nursing care. The purpose of this study was to analyze correlation intention with nurse behavior in documenting nursing care in Emergency Installation. The research design used correlational analysis with cross sectional approach. The sample in this research is part of nurse of executing at IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan and IGD RS Islam Malang. The sample of 45 nurses IGD and 341 documents were selected according to inclusion and exclusion criteria. The result of statistical analysis of gamma that there is a significant correlation between intention and nursing documentation behavior evidenced by value of p = 0,000, positive correlation direction and strong correlation value is proved by r = 0,739. Hospital and nurse IGD is expected to develop a good intention then formed good nursing documenting behavior as well.Keywords : Nurse IGD, Intention, Nursing Documentation. Abstrak: Lingkungan kerja IGD yang kompleks akan mempengaruhi kualitas perawatan, pelayanan kesehatan, termasuk dokumentasi yang dilakukan tidak tepat atau tidak lengkap. Dokumentasi keperawatan yang tidak lengkap menunjukkan proses asuhan keperawatan tidak berjalan dengan baik dan berkesinambungan. Intensi dalam pendokumentasian dapat memprediksi munculnya perilaku seseorang termasuk perilaku perawat khususnya dalam pendokumentasian asuhan keperawatan. Tujuan penelitian ini untuk menganalis hubungan intensi dengan perilaku perawat dalam pendokumentasian asuhan keperawatan di Instalasi Gawat Darurat. Desain penelitian menggunakan analysis correlationaldengan pendekatan cross sectional. Sampel dalam penelitian ini adalah sebagian perawat pelaksana di IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan Malang dan IGD RS Islam Malang. Sampel berjumlah 45 perawat IGD dan 341 dokumen dipilih sesuai dengan kriteria inklusi dan ekslusi. Hasil analisis statistik uji gammamenunjukkan terdapat hubungan signifikan antara intensi dengan perilaku pendokumentasian keperawatan dibuktikan dengan nilai p = 0,000, arah korelasi positif, dan nilai korelasi kuat dibuktikan dengan nilai r = 0,739. Rumah Sakit dan perawat IGD diharapkan mengembangkan intensi yang baik sehingga diharapkan terbentuk perilaku pendokumentasian keperawatan yang baik pula. Kata Kunci : Perawat IGD, Intensi, Dokumentasi Keperawatan.

scholarly journals Implantação da Comissão de Prevenção e Tratamento de Lesões na Pele em um Hospital Público

2018 ◽  
Vol 86 (24) ◽  
Author(s):  
Roberta Carozo Torres ◽  
Sacha Jamille de Oliveira ◽  
Ana Cristina Freire Abud ◽  
Rita Maria Viana Rego
Keyword(s):  
Patient Safety ◽  
Nursing Care ◽  
Public Hospital ◽  
Wounds And Injuries ◽  
Descriptive Study ◽  
Skin Lesions ◽  
Care Patient ◽  
Skin Injuries ◽  
Individualized Care ◽  
Prevention And Treatment

O cuidado aos indivíduos com lesões na pele é um desafio multiprofissional, porém com maiorresponsabilidade para a equipe de enfermagem, por ter a responsabilidade da execução dos curativos. Esteestudo objetivou relatar a experiência de implantação da Comissão de Prevenção e Tratamento de Lesões naPele (CPTLP) em um hospital público do estado de Sergipe. Trata-se de um estudo descritivo, do tipo relato deexperiência, realizado a partir da vivência profissional na CPTLP de um hospital público de Sergipe. Com ointuito de sistematizar a assistência aos portadores de feridas e aqueles com risco de desenvolvê-las, a equipeda CPTLP foi criada e organizada com a finalidade de prevenir e tratar lesões na pele dos pacientes internados.A CPTLP tem o enfermeiro como profissional de referência para esses cuidados tendo em vista o protagonismodesse profissional nesse cenário. Assim, a equipe da CPTLP tem conseguido minimizar o surgimento de lesõescomplexas, além de tratar de forma efetiva as existentes através do atendimento individualizado e educaçãodas equipes assistenciais.Palavras-chave: Ferimentos e lesões; Cuidados de Enfermagem; Segurança do Paciente. AbstractCare for individuals with skin lesions is a multiprofessional challenge, but with greater responsibility for thenursing team, for having responsibility for the dressings execution. This study aimed to report the experienceof the Commission for the Prevention and Treatment of Skin Injuries (CPTLP) implementation in a publichospital in the state of Sergipe. This is a descriptive study, of the experience report type, carried out from theprofessional experience in the CPTLP of a public hospital in Sergipe. To systematize assistance to woundpatients and those at risk of developing them, the CPTLP team was created and organized to prevent and treatinjuries to the patients' skin. The CPTLP has the nurse as a reference professional for such care in view of thisprofessional role in this scenario. Thus, the CPTLP team has managed to minimize the complex lesionsoccurrence, in addition to effectively treating existing ones through the individualized care and the care teams’education.Keywords: Wounds and Injuries; Nursing Care; Patient Safety.

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