A ward-based writing coach program to improve the quality of nursing documentation

2012 ◽  
Vol 32 (6) ◽  
pp. 647-651 ◽  
Author(s):  
Diana Jefferies ◽  
Maree Johnson ◽  
Daniel Nicholls ◽  
Shushila Lad
Keyword(s):  
Nursing Documentation ◽  
Coach Program ◽  
Quality Of Nursing

scholarly journals Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

2019 ◽  
Vol 1 (2) ◽  
pp. 32-39
Author(s):  
Rr.Tutik Sri Hariyati ◽  
Krisna Yetti Malawat ◽  
Retno Purwandari ◽  
Effy Afifah
Keyword(s):  
Legal Aspect ◽  
Legal Aspects ◽  
Control Group ◽  
Nursing Documentation ◽  
Study Approach ◽  
Before And After ◽  
Post Test ◽  
Nursing Activity ◽  
Quality Of Nursing

Background: Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity.Objective: The Purpose of research to identify the legal aspect and completeness of nursing documentation after applying electronic nursing documentation. Methods: Report study approach and using pre and post-test with the control group. Thirty Four documentation collected using consecutive sampling on one-week observation before and after using electronic nursing information. The research compared the legal aspect and completeness of data conducted before and after the implementation of the new system.Results: The study showed improvement of the legal aspects increased by 50% (4,40 to 8,00) and completeness documentation by 10.39%  (43,00 to 49,00) after used of a system.   Conclusion: Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care. Recommendation: Electronic nursing documentation can be done to support and increase the quality of nursing.  

Quality of Nursing Documentation at Bugando Medical Centre in tanzania: A retrospective Patients’ Medical records Audit

2018 ◽  
Vol 6 (2) ◽  
pp. 98
Author(s):  
Kija Malale ◽  
Dotto Hongera ◽  
esther rundu ◽  
Marco James Bhilananiye ◽  
Adam Mang’ Ombe ◽  
...  
Keyword(s):  
Medical Records ◽  
Medical Centre ◽  
Nursing Documentation ◽  
Bugando Medical ◽  
Bugando Medical Centre ◽  
Quality Of Nursing

scholarly journals Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

2016 ◽  
Vol 24 (0) ◽  
Author(s):  
Aline Tsuma Gaedke Nomura ◽  
Marcos Barragan da Silva ◽  
Miriam de Abreu Almeida
Keyword(s):  
University Hospital ◽  
Nursing Documentation ◽  
Hospital Accreditation ◽  
Hospital Nursing ◽  
Brazilian Version ◽  
Before And After ◽  
Joint Commission International ◽  
Nursing Diagnoses ◽  
Quality Of Nursing

ABSTRACT Objective: to analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation, using the Quality of Nursing Diagnoses, Interventions and Outcomes - Brazilian version (Q-DIO- Brazilian version). Method: observational study of interventions conducted in a university hospital. Nursing documentation of 112 medical records for the period before and 112 for the period after the hospital accreditation were compared using the Q-DIO instrument - Brazilian version. Data were statistically analyzed. Results: there was a significant improvement in the quality of nursing documentation. When the total score of the instrument was evaluated, a significant improvement was observed in 24 out of the 29 items (82.8%). Conclusion: there was commitment to the shift of culture by means of the interventions carried out, which resulted in the conquest of the quality seal ensured by the Joint Commission International.

A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation

2021 ◽  
pp. 084456212110180
Author(s):  
Krystle Martin ◽  
Rosemary Ricciardelli
Keyword(s):  
Mental Health ◽  
Best Practice ◽  
Critical Role ◽  
Missing Information ◽  
Nursing Documentation ◽  
Mental Health Nurses ◽  
Inaccurate Information ◽  
The Impact ◽  
Quality Of Nursing

Background Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information. Purpose Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients. Methods Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content. Results Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context. Conclusions The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.

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