Measurement of the Accuracy of Nursing Documentation in the Patient Record

2.50
Hdl Handle:
http://hdl.handle.net/10755/148438
Type:
Presentation
Title:
Measurement of the Accuracy of Nursing Documentation in the Patient Record
Abstract:
Measurement of the Accuracy of Nursing Documentation in the Patient Record
Conference Sponsor:Sigma Theta Tau International
Conference Year:2009
Author:Paans, Wolter, MSc, RN
P.I. Institution Name:Hanze University College Groningen, the Netherlands and the Catholic University Leuven
Title:Assistant Research Scientist
Co-Authors:Walter Sermeus, PhD, RN; Roos M. B. Nieweg, MSc, RN; Cees P. van der Schans, PhD, PT, CE
[Scientific Session Presentation] AIM. To determine the accuracy of the nursing documentation in patient records in general hospitals, including admission information, nursing diagnoses, interventions, and progress and outcome evaluations in patient records in general hospitals.BACKGROUND.  Nursing documentation is essential for quality of care; therefore it is important that the documentation is accurate. Accurate documentation contains admission information, structured diagnoses, formulated with a problem label, a cause (related factor) and signs and symptoms accomplished with nursing interventions and progress and outcome evaluations, linked to a diagnosis (1).METHOD. Record screening of 341 patient records was conducted in 35 wards in 10 hospitals in the Netherlands using the D-Catch measurement instrument which includes the following aspects: 1) Record structure, 2) Admission data, 3) Nursing diagnosis, 4) Nursing interventions, 5) Progress and outcome evaluations, 6) Legibility (readable handwriting or well typed).FINDINGS. Lowest median accuracy scores were found on the documentation of the interventions 3 (2-8), highest median scores were found on the admission,  progress and outcome evaluation, both 6 (2-8). Based on factor analyses two constructs were established. As a result of aggregation and recoding the scale scores to a 100-point scale, a mean score of 54 (sd 15) on the chronological, evaluative construct and of 40 (sd 27) on the diagnostic construct was found.CONCLUSIONS. Nursing documentation is generally poor to moderate and seems to be mainly chronological and evaluative in nature and less problem-focused. Records with several accurate diagnoses in most cases also contained inaccurate diagnoses. Progress and outcome evaluations were in most cases linked to a diagnosis, though these evaluations were not strictly written as a reflection on the diagnosis, but more as a general evaluation of the patient?s health status. 1.) Carpenito-Moyet, L.J. (2008) Nursing Diagnosis: Application to Clinical Practice, 12th edition, Wolters Kluwer, Lippincott, New York, p. 2-8.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleMeasurement of the Accuracy of Nursing Documentation in the Patient Recorden_GB
dc.identifier.urihttp://hdl.handle.net/10755/148438-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Measurement of the Accuracy of Nursing Documentation in the Patient Record</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2009</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Paans, Wolter, MSc, RN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Hanze University College Groningen, the Netherlands and the Catholic University Leuven</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Assistant Research Scientist</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">w.paans@pl.hanze.nl</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Walter Sermeus, PhD, RN; Roos M. B. Nieweg, MSc, RN; Cees P. van der Schans, PhD, PT, CE</td></tr><tr><td colspan="2" class="item-abstract">[Scientific Session Presentation] AIM. To determine the accuracy of the nursing documentation in patient records in general hospitals, including admission information, nursing diagnoses, interventions, and progress and outcome evaluations in patient records in general hospitals.BACKGROUND. &nbsp;Nursing documentation is essential for quality of care; therefore it is important that the documentation is accurate. Accurate documentation contains admission information, structured diagnoses, formulated with a problem label, a cause (related factor) and signs and symptoms accomplished with nursing interventions and progress and outcome evaluations, linked to a diagnosis (1).METHOD. Record screening of 341 patient records was conducted in 35 wards in 10 hospitals in the Netherlands using the D-Catch measurement instrument which includes the following aspects: 1) Record structure, 2) Admission data, 3) Nursing diagnosis, 4) Nursing interventions, 5) Progress and outcome evaluations, 6) Legibility (readable handwriting or well typed).FINDINGS. Lowest median accuracy scores were found on the documentation of the interventions 3 (2-8), highest median scores were found on the admission, &nbsp;progress and outcome evaluation, both 6 (2-8). Based on factor analyses two constructs were established. As a result of aggregation and recoding the scale scores to a 100-point scale, a mean score of 54 (sd 15) on the chronological, evaluative construct and of 40 (sd 27) on the diagnostic construct was found.CONCLUSIONS. Nursing documentation is generally poor to moderate and seems to be mainly chronological and evaluative in nature and less problem-focused. Records with several accurate diagnoses in most cases also contained inaccurate diagnoses. Progress and outcome evaluations were in most cases linked to a diagnosis, though these evaluations were not strictly written as a reflection on the diagnosis, but more as a general evaluation of the patient?s health status. 1.) Carpenito-Moyet, L.J. (2008) Nursing Diagnosis: Application to Clinical Practice, 12th edition, Wolters Kluwer, Lippincott, New York, p. 2-8.</td></tr></table>en_GB
dc.date.available2011-10-26T09:45:09Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T09:45:09Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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