Describing Professional Nursing through a Universal Clinical Record

2.50
Hdl Handle:
http://hdl.handle.net/10755/149398
Type:
Presentation
Title:
Describing Professional Nursing through a Universal Clinical Record
Abstract:
Describing Professional Nursing through a Universal Clinical Record
Conference Sponsor:Sigma Theta Tau International
Conference Year:2001
Conference Date:November 10 - 14, 2001
Author:Beyea, Suzanne, PhD
P.I. Institution Name:AORN
Title:Director of Nursing Research
DOCUMENTATION. The objective was to: 1) identify data elements that represent professional nurses' contributions to patient outcomes in surgical settings, and 2) establish a framework for a national perioperative database that will facilitate comparisons across information systems and clinical settings. OBJECTIVE: The purpose of this effort was to establish national standards for perioperative d. METHODS: A national sample of over 150 perioperative records representing both inpatient and ambulatory settings from for-profit, non-profit, and government agencies were collected and analyzed. Data elements that represented the intraoperative period were noted using a structured format. Two expert nurses conducted the analysis and achieved a high-level of inter-rater reliability when coding the clinical records. MAJOR FINDINGS: This analysis uncovered a disappointing reality about the current status of intraoperative nursing documentation. In fewer than 22% of the records were nursing diagnoses, nursing interventions or patient outcomes documented. An expert panel concluded that in surgical settings, the professional aspects of intraoperative nursing care are embedded in the care delivered and not accurately or fully represented in clinical documentation. It became apparent that the benefits of a structured vocabulary could only be fully realized when national documentation standards were established and implemented within and across settings. Nursing contributions can not be fully evaluated unless they represented and documented in clinical records. The use of structured vocabulary may assist nurses utilize standardized terms, but the most important factor is a nursing record that fully describes nursing practice. The ability to computerize clinical records will not help to evaluate the effectiveness of nursing practice until assessments, identified problems, interventions, and outcomes are consistently and appropriately documented. OUTCOMES: Based on these findings, a “best practice” approach was developed to identify key data fields for a perioperative record. These data fields consisted of nursing diagnoses, interventions, and outcomes as well as structural data elements based on a structured vocabulary specific to perioperative practice. This information has been disseminated to clinicians nationwide in ongoing efforts to work toward more uniform documentation across perioperative settings. Structured vocabulary becomes an academic exercise without careful and deliberate strategies to implement it in clinical settings and information systems. These national efforts demonstrate one approach to clearly recognizing, documenting, and evaluating the contributions of professional nurses in a specialty practice.
Repository Posting Date:
26-Oct-2011
Date of Publication:
10-Nov-2001
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleDescribing Professional Nursing through a Universal Clinical Recorden_GB
dc.identifier.urihttp://hdl.handle.net/10755/149398-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Describing Professional Nursing through a Universal Clinical 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">2001</td></tr><tr class="item-conference-date"><td class="label">Conference Date:</td><td class="value">November 10 - 14, 2001</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Beyea, Suzanne, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">AORN</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Director of Nursing Research</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">sbeyea@empire.net</td></tr><tr><td colspan="2" class="item-abstract">DOCUMENTATION. The objective was to: 1) identify data elements that represent professional nurses' contributions to patient outcomes in surgical settings, and 2) establish a framework for a national perioperative database that will facilitate comparisons across information systems and clinical settings. OBJECTIVE: The purpose of this effort was to establish national standards for perioperative d. METHODS: A national sample of over 150 perioperative records representing both inpatient and ambulatory settings from for-profit, non-profit, and government agencies were collected and analyzed. Data elements that represented the intraoperative period were noted using a structured format. Two expert nurses conducted the analysis and achieved a high-level of inter-rater reliability when coding the clinical records. MAJOR FINDINGS: This analysis uncovered a disappointing reality about the current status of intraoperative nursing documentation. In fewer than 22% of the records were nursing diagnoses, nursing interventions or patient outcomes documented. An expert panel concluded that in surgical settings, the professional aspects of intraoperative nursing care are embedded in the care delivered and not accurately or fully represented in clinical documentation. It became apparent that the benefits of a structured vocabulary could only be fully realized when national documentation standards were established and implemented within and across settings. Nursing contributions can not be fully evaluated unless they represented and documented in clinical records. The use of structured vocabulary may assist nurses utilize standardized terms, but the most important factor is a nursing record that fully describes nursing practice. The ability to computerize clinical records will not help to evaluate the effectiveness of nursing practice until assessments, identified problems, interventions, and outcomes are consistently and appropriately documented. OUTCOMES: Based on these findings, a &ldquo;best practice&rdquo; approach was developed to identify key data fields for a perioperative record. These data fields consisted of nursing diagnoses, interventions, and outcomes as well as structural data elements based on a structured vocabulary specific to perioperative practice. This information has been disseminated to clinicians nationwide in ongoing efforts to work toward more uniform documentation across perioperative settings. Structured vocabulary becomes an academic exercise without careful and deliberate strategies to implement it in clinical settings and information systems. These national efforts demonstrate one approach to clearly recognizing, documenting, and evaluating the contributions of professional nurses in a specialty practice.</td></tr></table>en_GB
dc.date.available2011-10-26T10:01:36Z-
dc.date.issued2001-11-10en_GB
dc.date.accessioned2011-10-26T10:01:36Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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