nursing records

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..DESIGN AND METHOD: A cross-sectional study design was used: a pretest (n = 355 nursing records) for baseline status of nursing documentation, an intervention and a post-test (n = 349 nursing records) to ..

..Relevance to clinical practice. New strategies for improving nursing documentation have been demonstrated...

..The question is raised whether catheterization is used as a convenience for nursing staff or as an essential aspect of care...

..Nurses must evaluate documentation completeness before and periodically after NIS implementation, using results to improve patient record data validity for patient care decisions, quality improvement, and research...

..Adopting a supportive multidisciplinary approach to quality improvement and providing education that emphasises written documentation of verbal communication are also recommended...

..Systematic evaluation was important to document successes as well as areas requiring further focus...

..The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from ..

..CONCLUSIONS: The implementation of an EBP educational programme focused on patient outcome rather than a task to be performed improved the quality of oral care delivered by the nursing staff...

..CONCLUSION: The Cat-ch-Ing EPI instrument shows a high reliability and validity as an audit instrument to evaluate the content of nursing discharge notes...

..Elaine Ballard's article focuses on health informatics, a field which has developed with limited input from nurses who provide direct care...

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..CONCLUSION: Through this project, nurses, midwives and lady health visitors (midwives, vaccinator and health educators) will test standardization of documentation and begin to evaluate efficiency and effectiveness of clinical practice...

..Furthermore, this article gives a brief overview of the history of the PNDS, and how this language helps improve nursing outcomes and promotes the profession of nursing...

..A subsequent audit showed improved coordination of BGL measurement and insulin administration in relation to meals, sustained over eighteen months, and increased accuracy in documentation...

..An education programme was developed to highlight the incidence of eye surface disease and importance of eye care in the ventilated patient...

..This was developed in the intensive care unit of the Royal Free Hospital, London and is presently in use...

..6% of entries it was not possible to identify who initiated the request for medication and in 9.1% of cases no reason was given for the administration of PRN medication...

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..use of pedagogically related keywords and the content of notes connected to these keywords, as they appear in nursing records in a coronary artery bypass graft (CABG) surgery rehabilitation unit...

..A post implementation audit suggests that once staff were familiar with the guide, handovers became more structured and informative...

..The staff has become more resource-oriented and the patient has, to a much larger extent than before, become an active participant in the development of the nursing plan...

..It is expected that better use of standardized care plans will enhance nurses' access to appropriate and accurate information in decision-making, thus improving the charting process and care quality...

..CONCLUSION: Further improvements in care are necessary, as are qualitative and quantitative studies to explore the large discrepancies between guidelines and everyday clinical practice in this field...

..Studies that use only precomparison and postcomparison by chart audit may miss changes in nursing practice...

..Appropriate interventions identified on the risk-assessment tool were put into place inconsistently. As a result of this work the hospital has set up a multidisciplinary group to look at falls management...

..The record review process can facilitate a clinician's understanding about documentation standards and requirements as well as help to maintain a state-of-audit readiness of the record for regulatory and accrediting surveys...

..The results demonstrate that nurses can use MDS and TSCS data on patient outcomes to gain insight into the effectiveness of their interventions...

..The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process...

..Opportunities to combine these two approaches are highlighted through scenarios. Recommendations are made for nurses to adapt their current information systems and better manage their clinical information...

..Further to indicate how a theory and specific procedure can be used to guide the process of implementation throughout the different levels of management...

..In the UK, conservative estimates suggest that 424 million pounds per year is spent on urinary incontinence alone (Continence Foundation, 2000)...

..This article will address this topic...

..A statistically significant improvement in outcome ratings from admission to discharge was demonstrated for seven of eight NOC outcomes...

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..PICU) of a large UK children's hospital and an audit was undertaken to compare the standard of handwritten nursing records in the PICU with that of the computerised nursing records in the high dependency unit (HDU)...

..Recommendations include establishment of an attendance referral policy and improved documentation systems, including the use of standardized nursing language to demonstrate student outcomes...

..The knowledge of nursing interventions used in clinical practice has major implications for staff development and nursing education. The information is also useful in making staffing decisions for different types of patient populations...

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..This audit showed that a wide variation in attitude towards disposal of CDs exists among medical and non-medical staff, and that the sample hospitals are falling short of meeting proposed standards...

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..This nurse-led project demonstrated how positive outcomes and improvements could be achieved with record keeping across the multidisciplinary ITU team...

..Furthermore their strength as a learning tool was attributed to team learning as a powerful catalyst for change...

..Further research is recommended on competence of newly qualified registered nurses at other nursing colleges or similar context...

..More research is needed to establish whether these findings are matched in practice, and to identify whether the results found in one teaching hospital are equally true for other types of hospital in the UK...

..9% of the variance in intervention time. CONCLUSIONS: The use of the standardized nursing terminology enabled calculation of the intervention dose and documentation that a tailored intervention was delivered...

..The keys to success in this ongoing audit programme are identified as stakeholder involvement, support from the senior nurses in the organization and the use of the data for both local and trust-wide purposes...