235:
243:
improvement in documentation quality is not necessarily to be brought about by the introduction of electronic nursing documentation system to replace paper-based documentation. For example, Wang et al. that although the electronic nursing assessment form contained more documented assessment forms, which covered a wider range of resident care needs, they did not perform better than the previous the quality criteria of and timeliness. Therefore, further work on the usage of the electronic documentation systems may focus on improving form design and usage. There is also a need for improvement in compliance with standards in order to better meet the clients' care needs.
168:(NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. Nowadays, the NCP is widely used in nursing in various clinical and educational settings as a tool to direct individualized nursing care for clients.
38:. Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.
1242:
330:
nurses with cohesive and accurate information determined by the format of the care plan. The clarity of the recorded information also facilitates clinical auditing and evaluation of documentation practices through. Therefore, the introduction of structured documentation and care plans are seen as a means by which nurses can raise standards of record-keeping practice.
422:
Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care 9, 6-13. Kern C.S., Bush K.L. & McCleish J.M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an alternative to traditional care plans. Journal of
Nursing Education 45(4), 112-119.
1266:
172:
Australian residential aged care home may be structured with several sections under each care domain such as pain, mobility, lifestyle, nutrition and continence. The information is recorded in free-text style, and various terms are used singly or in combination to name each of the four sections in the formats that are used by a facility during a particular period
1254:
227:
counterpart. In addition, in comparison with the paper-based documentation systems, the electronic systems, due to their automatic functions, were able to improve the format, structure and process features of documentation quality such as legibility, signing, dating, crossing out error and space with a single line and resident identification on every page.
223:
include the improvement of comprehensiveness in documenting the nursing process, the use of standardized language and the recording of specific items about particular client issues and relevance of the message. In addition, electronic systems can improve legibility, dating and signing in nursing records.
222:
Electronic nursing documentation systems are able to produce somewhat better quality data in comparison with paper-based systems, in certain respects depending on the characteristics of the systems and the practice of the various study settings. The common benefits of electronic documentation systems
147:
During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. Complete and accurate nursing assessment determines the accuracy of the other stages of
122:
The admission form provides the basic information to establish foundations for further nursing assessment. It usually contains the general data about a client, such as name, gender, age, birth date, address, contact, identification information (ID) and some situational descriptions about marriage,
421:
Neilson T., Peet M., Ledsham R. & Poole J. (1996) Does the nursing care plan help in the management of psychiatric risk? Journal of
Advanced Nursing 24,1201-1206 Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.
329:
Structured documentation takes the form of pre-printed guidelines for specific aspects of care and can, therefore, focus nursing care upon diagnoses, treatment aims, client outcomes and evaluations of care. It can improve client care by replacing the practice of vague, narrative style entries by
226:
For the documentation of nursing assessment, the electronic systems significantly increased the quantity and comprehensiveness of documented assessment forms in each record. In regard to the NCP, the electronic standardized NCPs were graded with a higher total quality score than its paper-based
320:
The
International Classification for Nursing Practice (ICNP) is a collaborative project under the auspices of the International Council of Nurses. The ICNP provides a structured and defined vocabulary as well as a classification for nursing and a framework into which existing vocabularies and
251:
A study by the
National Client Safety Agency (NPSA) found that poor standards of documentation were a contributory factor in the failure to detect clients who were clinically deteriorating. Nurses are responsible for maintaining accurate records of the care they provide and are accountable if
283:
NANDA International (formerly the North
American Nursing Diagnosis Association) is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing
230:
Paper-based documentation has been found to be inferior in comparison with electronic documentation. This is caused by the inherent nature of paper being difficult to update, time-consuming in a recording. Thus, the records are often incomplete, illegible, repetitive and missing signatures.
171:
The nurses make nursing care plans based on the assessments they have completed previously with a client. There are many ways of structuring nursing care plans in correspondence with the different needs of nursing care in different nursing specialties. For example, a nursing care plan in an
242:
Electronic nursing documentation systems have the potential to improve the quality of documentation structure and format, process and content in comparison with paper-based documentation, as demonstrated in a comparative study of electronic and paper-based nursing admission forms. However,
82:, nursing problem/diagnosis, goal, intervention and evaluation. Nursing process model provides the theoretical framework for nursing documentation. A nurse can follow this model to assess the clinical situation of a client and record a constructive document for nursing communication.
143:
The documentation of nursing assessment is the recording of the process about how a judgment was made and its related factors, in addition to the result of the judgment. It makes the process of nursing assessment visible through what is presented in the documentation content.
488: Wang, N., Yu, P., & Hailey, D. (2012). Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities. International Journal of Medical Informatics, doi:10.1016/j.ijmedinf.2012.11.011
267:
Quality of documentation content: refers to the message from data about a care process. It is concerned with the comprehensiveness, appropriateness and the relation- ship of the five steps of the nursing process. The care issue recorded at each step is also
313:
The Omaha System is a standardized health care terminology consisting of an assessment component (Problem
Classification Scheme), a care plan/services component (Intervention Scheme), and an evaluation component (Problem Rating Scale for Outcomes).
114:
is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care. The form is completed by a nurse when a client is admitted to a
155:
records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing process.
293:
The
Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan.
263:
Quality of documentation process: the procedural issues of capturing client data such as nurse's signature and designation, date, chronological order, timeliness, regularity of documentation and concordance between documentation and
213:
have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery.
200:
The paper-based nursing documentation has been in place for decades. Client's data are recorded in paper documents. The information in these documents needs to be integrated for sense-making in a nursing decision.
449:
Kern C.S., Bush K.L. & McCleish J.M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an alternative to traditional care plans. Journal of
Nursing Education 45(4), 112-119.
259:
Quality of documentation structure and format: relates to constructive features and physical presentation of records such as quantity, completeness, legibility, read- ability, redundancy and the use of
467:
Zhang Y, Yu P, Shen J. The benefits of introducing electronic health records in residential aged care facilities:A multiple case study. Interna- tional
Journal of Medical Informatics 2012; 81: 690–704.
187:
Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
943:
1176:
1131:
550: Irvine K, Tracey M, Scott A, Hyde A, Butler M, MacNeela P (2006) Discursive practices in the documentation of client assessments. Journal of Advanced in Nursing 53(2): 151–9
541:
Dahm M, Wadensten B (2008) Nurses' experiences of and opinions about using standardised care plans in electronic health records; a questionnaire study. J Clin Nurs 17(16): 2137–45
98:. The following sections describe the concept, aim, possible structure and content of these nursing documents using the example of nursing documentation in Australian residential
234:
515:
Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: A mixed-method systematic review. Journal of
Advanced Nursing 2011; 67: 1858–1875.
440:
Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care 9, 6-13.
255:
The systematic review of nursing documentation audit studies in different settings identified the following relevant quality characteristics of nursing documentation:
346:
Björvell C,Thorell-Ekstrand I.Wredling R.Development of an audit instrument for nursing care plans in the client record. Quality in Health Care 2000; 9: 6–13.
734:
1216:
476:
Ammenwerth E,Eichstadter R,Haux R et al.A randomized evaluation of a computer-based nursing documentation system. Method Inform Med 2001; 40: 61–68.
1226:
373:
Oroviogoicoechea C., Elliott B. & Watson S. (2008) Review: evaluating information systems in nursing. Journal of Clinical Nursing 17, 567–575.
184:
is the record of nursing actions and observations in the nursing care process. It helps nurses to monitor and control the course of nursing care.
497:
National Clients Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospital clients. NPSA, London.
821:
806:
1038:
998:
91:
1094:
714:
287:
724:
303:
The Nursing Outcomes Classification (NOC) is a classification system which describes client outcomes sensitive to nursing intervention.
60:
Show the use of the nursing process. It contains observations by the nurses about the client's condition, care, and treatment delivered.
559:
Saranto K, Kinnunen U (2009) Evaluating nursing documentation-research designs and methods: systematic review. J Adv Nurs 65(3): 464–76
1192:
826:
596:
90:
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous
431:
Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.
1270:
382:
Crisp J., Taylor C., Potter PA. & Perry A.G. (2005) POTTER and PERRY'S fundamentals of nursing (2nd ed). Elsevier Australia.
1104:
771:
297:
776:
132:
123:
work or other background information. Based on the different nursing care provider's requirements, this form may also record
57:
Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given.
568:
Law L, Akroyd K, Burke L (2010) Improving nursing documentation and record-keeping in stoma care. Br J Nurs 19(21): 1328–32
524:
Wake, M., & Coenen, A. (1998). Nursing diagnosis in the international classification for nursing practice (icnp).
1212:
1297:
1222:
791:
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94:, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the
252:
information is incomplete and inaccurate. Thus, a quality standard is required for recording of nursing documentation.
1114:
968:
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Blair, W., & Smith, B. (n.d). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168.
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Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses.
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of the history, treatment, care, and response of the client while under the care of a health care provider.
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under the direction of a qualified nurse. It contains information in accordance with the steps of the
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The nursing documents may contain a number of assessment forms. In an assessment form, a licensed
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403: L. White, Documentation and the Nursing Process, Delmar Learning, Clifton Park, NY, 2002.
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Greenwood D. (1996) Nursing care plans: issues and solutions. Nursing Management 27(3), 33-40.
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Figure 3–2. An example of a nursing care plan in an Australian residential aged care home
394:
White L. (2002) Documentation and the Nursing Process. Delmar Learning, Clifton Park, NY
63:
Provides data for quality assurance studies and shows progress toward expected outcomes.
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364: "General Info". Archived from the original on 12 March 2009. Retrieved 2009-04-03
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classifications can be cross-mapped to enable comparison of nursing data.
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Owen K (2005) Documentation in nursing practice. Nurse Stand 19(32): 48–9
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Comparison of the quality of paper-based and electronic documentation
78:
The internationally accepted nursing process consists of five steps:
1089:
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458:"UW Internal Medicine Residency Program". Retrieved 2009-04-10
278:
North American Nursing Diagnosis Association (NANDA)
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International Classification for Nursing Practice (ICNP):
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26:that is planned and delivered to individual
526:International Journal of Nursing Knowledge,
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288:Nursing intervention classification (NIC)
211:Electronic nursing documentation systems
54:A guide for reimbursement of care costs.
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807:Nursing credentials and certifications
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7:
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1095:Nursing Interventions Classification
298:Nursing outcome classification (NOC)
68:Documentation of the nursing process
1265:
14:
196:Paper-based nursing documentation
1264:
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273:Standardized nursing terminology
247:Quality of nursing documentation
205:Electronic nursing documentation
1105:Nursing Outcomes Classification
1100:Nursing Minimum Data Set (NMDS)
772:Associate of Science in Nursing
777:Bachelor of Science in Nursing
1:
999:Psychiatric and mental health
30:by qualified nurses or other
792:Master of Science in Nursing
135:, and allergies in nursing
1324:
787:Doctor of Nursing Practice
133:history of present illness
71:
1236:
944:Women's Health Care Nurse
679:Clinical nurse specialist
1123:International Nurses Day
639:Licensed practical nurse
325:Structured documentation
802:Nurse Licensure Compact
16:Records of nursing care
239:
1034:Travel health nursing
634:Clinical nurse leader
237:
148:the nursing process.
20:Nursing documentation
859:Correctional nursing
129:past medical history
117:health care facility
1298:Nursing informatics
1193:Republic of Ireland
969:Occupational health
959:Nursing informatics
735:Psych/mental health
280:nursing diagnosis:
1057:Nursing assessment
919:Legal consultation
782:Diploma in Nursing
767:Nightingale Pledge
694:Nurse practitioner
240:
1280:
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1067:Nursing care plan
1062:Nursing diagnosis
747:
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715:Adult-gerontology
703:NPs by population
684:Nurse anesthetist
664:Advanced practice
308:Omaha System
166:nursing care plan
160:Nursing care plan
22:is the record of
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837:Specialties and
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153:Registered Nurse
92:assessment forms
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182:progress note
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41:
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33:
29:
25:
21:
1269:
1258:
1245:
1198:South Africa
1004:Private duty
672:APNs by role
564:
555:
546:
537:
529:
525:
520:
511:
502:
493:
472:
463:
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121:
109:
89:
77:
24:nursing care
19:
18:
1271:WikiProject
1188:Philippines
1173:New Zealand
1029:Telenursing
979:Orthopedics
909:Home health
622:Generalists
284:diagnoses.
268:considered.
1287:Categories
1115:By country
984:Pediatrics
964:Obstetrics
924:Management
914:Hyperbaric
899:Geriatrics
720:Pediatrics
613:Levels of
334:References
139:Assessment
80:assessment
72:See also:
32:caregivers
1308:Documents
1148:Hong Kong
1128:Australia
939:Midwifery
879:Emergency
874:Education
839:areas of
759:licensure
753:Education
532:(4), 335.
106:Admission
100:aged care
1247:Category
1183:Pakistan
1177:timeline
1132:timeline
1024:Surgical
974:Oncology
954:Neonatal
949:Military
904:Holistic
894:Forensic
841:practice
730:Neonatal
615:practice
264:reality.
42:Purposes
1293:Nursing
1259:Commons
1227:history
1217:history
1143:Germany
1083:systems
854:Cardiac
606:Nursing
102:homes.
86:Content
28:clients
1208:Taiwan
1138:Canada
1014:School
929:Matron
889:Flight
869:Dental
710:Family
528:
1203:Spain
1168:Kenya
1163:Japan
1153:India
1090:NANDA
1019:Space
822:NCLEX
1158:Iran
1039:WOCN
827:TEAS
756:and
306:The
164:The
110:An
1289::
481:^
387:^
310::
300::
290::
180:A
131:,
127:,
119:.
47:A
1229:)
1225:(
1219:)
1215:(
1179:)
1175:(
1134:)
1130:(
598:e
591:t
584:v
530:5
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