2.50
Hdl Handle:
http://hdl.handle.net/10755/159221
Type:
Presentation
Title:
Documentation of Nursing Care: Representing the Softer Elements
Abstract:
Documentation of Nursing Care: Representing the Softer Elements
Conference Sponsor:Midwest Nursing Research Society
Conference Year:2004
Author:Heinzer, Marjorie, PhD, MSN, RN, CS, CRNP
Title:Associate Professor
Contact Address:Frances Payne Bolton, SON, 10900 Euclid Avenue, Cleveland, OH, 44106-4904 , USA
Nursing notes have historically told the patient’s story of nursing care during a hospitalization. Graphs, flow sheets, checklists, and more recently, computerization facilitate the documentation of specific elements of care, yet nurses appear reluctant to relinquish the narrative note. Consequently, the purpose of this study was to explore what registered nurses in an urban health center believe are the essential components of a nursing note, the ways that nursing data are communicated, and barriers to documentation. The study design was qualitative in nature and utilized focus groups (Sim, 1998). Twenty four nurses participated in four focus groups of five to eight members each. Sessions were audio taped, recorded on flip charts, and transcribed verbatim following completion of the group. Themes that arose from the questions that dealt with the content of documentation were evidence of care, quality issues, interaction patterns, clarification, and the complete picture of the patient’s experience. Essential components of nursing notes were records of delivery of care, understanding the patient experience, communication of needs, ethical issues, collaborative processes, review of activity or patient progress, prevention of duplication of services, psychosocial concerns, and accountability. Participants shared that nursing is “doing” and writing in the chart reflects a small percentage of the nursing care given. Verbal report, team meetings, nursing rounds notes, summaries, and kardex entries provided other valued venues for communication. All focus groups agreed that documentation underrepresented the actual nursing work. Psychosocial components and indirect care activities that are not quantified on checklists are important to understanding the patient experience. Computerized clinical documentation systems may need to address free text entry and detailed menus to capture the “softer” care issues that are missed on data bit format. The system itself requires a change in mindset, knowledge, performance, and skills.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Midwest Nursing Research Society

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleDocumentation of Nursing Care: Representing the Softer Elementsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/159221-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Documentation of Nursing Care: Representing the Softer Elements </td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Midwest Nursing Research Society</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2004</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Heinzer, Marjorie, PhD, MSN, RN, CS, CRNP</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Associate Professor</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">Frances Payne Bolton, SON, 10900 Euclid Avenue, Cleveland, OH, 44106-4904 , USA</td></tr><tr><td colspan="2" class="item-abstract">Nursing notes have historically told the patient&rsquo;s story of nursing care during a hospitalization. Graphs, flow sheets, checklists, and more recently, computerization facilitate the documentation of specific elements of care, yet nurses appear reluctant to relinquish the narrative note. Consequently, the purpose of this study was to explore what registered nurses in an urban health center believe are the essential components of a nursing note, the ways that nursing data are communicated, and barriers to documentation. The study design was qualitative in nature and utilized focus groups (Sim, 1998). Twenty four nurses participated in four focus groups of five to eight members each. Sessions were audio taped, recorded on flip charts, and transcribed verbatim following completion of the group. Themes that arose from the questions that dealt with the content of documentation were evidence of care, quality issues, interaction patterns, clarification, and the complete picture of the patient&rsquo;s experience. Essential components of nursing notes were records of delivery of care, understanding the patient experience, communication of needs, ethical issues, collaborative processes, review of activity or patient progress, prevention of duplication of services, psychosocial concerns, and accountability. Participants shared that nursing is &ldquo;doing&rdquo; and writing in the chart reflects a small percentage of the nursing care given. Verbal report, team meetings, nursing rounds notes, summaries, and kardex entries provided other valued venues for communication. All focus groups agreed that documentation underrepresented the actual nursing work. Psychosocial components and indirect care activities that are not quantified on checklists are important to understanding the patient experience. Computerized clinical documentation systems may need to address free text entry and detailed menus to capture the &ldquo;softer&rdquo; care issues that are missed on data bit format. The system itself requires a change in mindset, knowledge, performance, and skills. </td></tr></table>en_GB
dc.date.available2011-10-26T21:49:04Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T21:49:04Z-
dc.description.sponsorshipMidwest Nursing Research Societyen_GB
All Items in this repository are protected by copyright, with all rights reserved, unless otherwise indicated.