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PubMed1999

Documentation practices of nurses in long-term care.

Documentation of nursing care is an important source of reference and communication between nurses and other health care providers. This article describes a study of the documentation practices of nurses in a long-term care institution. Results revealed a number of positive aspects of nurses' documentation practices and areas requiring modification or change which could be facilitated through redesigning the documentation system. Implications for professional practice are discussed, which include the need for a concise, non-duplicating system of documentation, and the importance of nursing documentation in support of evidence-based practice.

Aged↗
PubMed2002

Nursing documentation of postoperative pain management.

Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware.

Adult↗
PubMed2002

Long-term increase in quality of nursing documentation: effects of a comprehensive intervention.

This study aimed to evaluate the longitudinal effects of a nursing-documentation intervention on the quantity and quality of the nursing documentation in a sample of patient records at a university hospital in Stockholm, Sweden. In this quasi-experimental longitudinal study, two hospital wards participated in a 2-year intervention and a third ward was used for comparison. The intervention consisted of organizational changes and education regarding nursing documentation in accordance with the VIPS model, a model designed to structure nursing documentation. To evaluate the effect, patient records were audited at three different time points: before the intervention, directly after the intervention and 3 years after the intervention. A total of 269 patient records were used. The findings showed a significant score increase in quantity as well as in quality of the nursing documentation, in the intervention wards directly after the intervention, as compared with those from the comparison ward. The results suggests that a comprehensive intervention based on the VIPS model and including organizational support for registered nurses (RN) may improve nursing documentation in an acute care hospital setting.

Adult↗
PubMed2001

Documentation of pain assessment and treatment: how are we doing?

The purpose of this analysis was to evaluate documentation of practice provided by a multidisciplinary team of nurses, physicians, and pharmacists who participated in an educational program on postoperative pain management. Chart audit of 787 patient charts at 6 sites revealed documentation of pain histories in approximately 75% of the charts, most often in the surgeon's history and physical examination. Examination of multiple assessment items indicated that the experimental group, relative to the control group, experienced an increase of more than 10% in the documentation of pain intensity, pain quality, pain duration, numeric rating scale used, pain behavior, factors that increase pain, vital signs, sedation level, cognitive status, social interaction, and mood from before the program to 6 months after the program. Across all sites, documentation of assessment, treatment, and treatment outcome data was infrequent and inconsistent. Calculation of documentation of 4 items that constituted a focused assessment of postoperative pain on the surgical floor revealed a significant program effect for assessment of pain quality and pain intensity. A postprogram survey of participants in the educational program revealed an increase in discussion of postoperative pain management with other practitioners and an increase in use of a 0 to 10 scale to rate pain. More documentation of patient pain history, clinical problems, treatment, and follow-up action is needed to improve practice and research.

Clinical Competence↗
PubMed1989

Computerized documentation for lithium outpatients (routine and research data).

To follow up the status and further outcome of patients with recurrent affective and schizoaffective disorders treated in a lithium/prophylactic treatment outpatient (LOP) clinic the authors have developed a documentation system based on a database, which ASCII files. This system should be useful as a basis for optimal treatment and is helpful for special research purposes regarding prophylactic treatment (lithium salts, carbamazepine, antidepressants, etc.). The documentation system consists of two parts, one for routine documentation system consists of two parts, one for routine monitoring including basic data, global course, and routine form with side-effects, and another one for research purposes with documentation of laboratory findings, EEG, and documentation of every cycle which can be added easily. Moreover, with this documentation system it will be possible to compare results from different research centres.

Computers↗
PubMed2001

Just the facts, please: a guide to effective documentation.

Although most health care professionals would wish it otherwise, documentation will never be eliminated completely. It can be ignored and complained about, but documentation will always be there to remind us, "If it wasn't documented, it wasn't done." Home care providers need to be cognizant of the imperative for effective documentation. Corporate compliance initiatives, fraud and abuse issues, and changes in reimbursement mechanisms make documentation more important than ever. Home care providers must create an environment conducive to effective documentation practices.

Documentation↗
PubMed2003

Significant improvement in quality of caesarean section documentation with dedicated operative proforma--completion of the audit cycle.

In the current climate of rising caesarean section rates coupled with the increasingly litigious nature of modern medical practice, and particularly obstetrics, well-documented operative notes are important. We therefore set out to audit the quality of caesarean section documentation in a busy Greater London University Hospital with over 4500 deliveries per annum. The study involved 137 case notes between 1 November and 31 December 1999 and the same number at re-audit 2 years later. The results of the initial audit showed important omissions in a high percentage of operative delivery notes, with less than 80% of case notes documenting skin incision time and type, surgical findings of note, type of uterine incision, presenting part, explanation of fetal delivery, uterine cavity check, presence of a paediatrician, adnexal check and complete sutures used. CNST (Clinical Negligence Scheme for Trusts) guidelines were not adhered to, with only 41% and 35% of delivery notes having complete signature with printed name and correct time and date, respectively. There was considerable confusion at the use of the terminology for level of urgency of non-elective sections and the umbilical cord blood gas results were also poorly documented. As a consequence of these findings a dedicated 'operative delivery note' proforma was designed according to CNST guidelines, with clear areas for particular details of note such as the clinician's name and grade, cord pH results as well as the more important surgical findings. It also simplified the documentation of the urgency of the procedure. There was a significant improvement in almost all items assessed. We therefore conclude that the use of a specific dedicated operative proforma leads to significantly improved documentation with potentially beneficial medicolegal implications.

Cesarean Section↗
PubMed2003

Using personal digital assistants to document pharmacist cognitive services and estimate potential reimbursement.

The use of personal digital assistants (PDAs) to document pharmacist cognitive services and estimate potential reimbursement was studied. Between September 2001 and February 2002, four pharmacy residents and four clinical pharmacists used PDAs for documenting cognitive services. Interventions recorded on paper during the same six-month period one year earlier were reviewed for comparison. Potential reimbursement for these services was calculated by linking current procedural terminology codes and charges to the electronically documented services. Over the six-month study period, pharmacists recorded 7319 interventions with PDAs, compared with 5028 documented on paper during the earlier six-month period. Potential claims for pharmacists' cognitive services documented with PDAs amounted to more than $1 million in the six months, assuming a 100% reimbursement rate. PDAs provide a simple, efficient paperless system for documenting pharmacists' clinical services and generating reimbursement claims.

Computers, Handheld↗
PubMed1996

Quality of documentation in medical reports of diabetic patients.

In a retrospective analysis of 752 consecutive medical reports of patients with insulin- or non-insulin-dependent diabetes mellitus, we investigated the completeness of documentation of indicators of quality of care. The medical reports are the currently used form of documentation which is sent to the General Practitioner after the patient's discharge from hospital. The indicators of care were data on clinical history, physical examination, laboratory results and secondary complications. The documentation was incomplete; e.g. in 8.0% of insulin-dependent (IDDM) and in 26.4% of non-insulin-dependent diabetics (NIDDM), HbA1c was missing. In 7.6%, the type of diabetes was not stated. The frequency of recorded secondary complications was lower than it has to be expected considering metabolic control and duration of diabetes of the studied group. Documentation was more complete for IDDM patients. The reports of NIDDM patients with incipient or overt diabetic nephropathy revealed less frequent recordings of data on lipid metabolism and blood pressure compared to the group without nephropathy. The documentation of indicators of quality of care in medical reports for general practitioners is incomplete for many diabetic inpatients. Standardized methods of documentation are required urgently.

Adolescent↗
PubMed1999

Improving nursing documentation for private-duty home health care.

Private-duty, home health care agencies have struggled in assuring compliance with accurate and complete nursing documentation. In this descriptive study, the author reports on an improvement and innovation project in a private-duty, home health care agency aimed at improving nursing documentation, as measured in chart review audits. Initial strategies were directed toward revising the documentation system, with implementation of a flow record, and conducting group nurse education. These efforts had a minimal effect on improving documentation compliance. A major, multifocus strategy was then implemented. The educational component stressed pre- and posttest. The chart audit tool was revised to track individual nurse behaviors. Nurses were mentored when documentation did not meet standards. Lastly, the nurse job description and corresponding performance appraisal document were revised to clarify nurse responsibility and strengthen nurse accountability; progressive discipline was initiated when warranted. Significant and sustained improvement was subsequently realized.

Documentation↗
PubMed2001

Effects of billing and documentation requirements on the quantity and quality of teaching by attending physicians.

PURPOSE: The Health Care Financing Administration's guidelines for billing and documentation by attending physicians have increased the amount of time that attending physicians spend documenting the services that they provide for patients. This study assessed the impact of these guidelines on attending physicians' teaching of housestaff on inpatient medical wards. METHOD: A survey of 92 housestaff from the department of medicine at one teaching hospital was conducted in 1998 to determine how attending physicians' billing and documentation requirements, clinic responsibilities, teaching styles, and inpatient census affected the quantity and quality of their teaching. The questionnaire included a rank-order analysis of factors affecting quantity and quality of attending physicians' teaching, as well as a five-point Likert scale assessing the quality of attending physicians' teaching. RESULTS: All housestaff responded. A total of 39% of housestaff perceived billing and documentation requirements to be the major detriment to quantity of teaching by attending physicians, and 30% perceived these requirements to be the major detriment to quality of teaching by attending physicians. Housestaff perceived more teaching and higher-quality teaching on services where attending physicians did not perform billing and documentation during teaching rounds. CONCLUSION: Billing and documentation requirements are a major detriment to the quantity of teaching on inpatient services, especially when faculty attempt to meet these requirements during teaching rounds.

Attitude of Health Personnel↗
PubMed2004

Documentation systems for educators seeking academic promotion in U.S. medical schools.

PURPOSE: To explore the state and use of teaching portfolios in promotion and tenure in U.S. medical schools. METHOD: A two-phase qualitative study using a Web-based search procedure and telephone interviews was conducted. The first phase assessed the penetration of teaching portfolio-like systems in U.S. medical schools using a keyword search of medical school Web sites. The second phase examined the current use of teaching portfolios in 16 U.S. medical schools that reported their use in a survey in 1992. The individual designated as having primary responsibility for faculty appointments/promotions was contacted to participate in a 30-60 minute interview. RESULTS: The Phase 1 search of U.S. medical schools' Web sites revealed that 76 medical schools have Web-based access to information on documenting educational activities for promotion. A total of 16 of 17 medical schools responded to Phase 2. All 16 continued to use a portfolio-like system in 2003. Two documentation categories, honors/awards and philosophy/personal statement regarding education, were included by six more of these schools than used these categories in 1992. Dissemination of work to colleagues is now a key inclusion at 15 of the Phase 2 schools. The most common type of evidence used to document education was learner and/or peer ratings with infrequent use of outcome measures and internal/external review. CONCLUSIONS: The number of medical schools whose promotion packets include portfolio-like documentation associated with a faculty member's excellence in education has increased by more than 400% in just over ten years. Among early-responder schools the types of documentation categories have increased, but students' ratings of teaching remain the primary evidence used to document the quality or outcomes of the educational efforts reported.

Adult↗
PubMed2001

Documentation and log keeping: ensuring your work does what you intend it to do.

Maintaining regular documentation, such as a log-book, can be an organization's most important asset when dealing with radiation protection issues, both normal and abnormal. When an organization is faced with litigation, proper documentation of events can ensure that a record is acceptable and, by extension, that the data itself is acceptable. A record of events will not preclude litigation, nor will it guarantee that an organization will prevail in a court of law, but it will provide evidence and credibility that could favorably affect the outcome of litigation. An organization can ensure that the documents it creates and maintains are as effective as possible by being aware of the legal consequences of documenting events and taking appropriate steps to conform to standards for admission of documentation. Misconceptions about log keeping such as recording only events that are likely to result in litigation, rather than recording all events, can prevent a record from being admissible as evidence. Because of the amount of effort and time put into documentation, and the reliance placed on its contents, it is important for an organization to ensure that a record will do what it is intended to do, namely to accurately record activities. Issues discussed in this article include the legal basis of documentary evidence, what and what not to record, when and how to record it, and how to strengthen the records kept.

Documentation↗
PubMed2003

Nursing documentation time during implementation of an electronic medical record.

OBJECTIVE: To determine, within the context of all nursing duties, the amount of time nurses spend on documentation during the implementation of an electronic medical record (EMR) on an intrapartum unit. BACKGROUND: Increased documentation needs during EMR implementation may necessitate increased staffing requirements in an already labor-intensive and demanding environment. METHODS: A work-sampling study was conducted over a 14-day study period, and 18 of 84 (21%) potential 4-hour observation periods were selected. During each period, a single observer made 120 observations and, on locating a specific nurse, immediately recorded that nurse's activity on a standardized and validated instrument. Categories of nursing activities included documentation, bedside care, bedside supportive care, nonbedside care, and nonpatient care. RESULTS: A total of 2160 observations were made. The total percentage of nursing time spent for documentation was 15.8%, 10.6% on paper and 5.2% on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2% vs 12.4%, respectively). CONCLUSIONS: Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor "double charting" occurred.

Documentation↗
PubMedDate not supplied

Accuracy and quality in the nursing documentation of pressure ulcers: a comparison of record content and patient examination.

OBJECTIVE: To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting. DESIGN: A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients. SETTING AND SUBJECTS: All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital. INSTRUMENTS: The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation. METHODS: All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments. RESULTS: The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor. CONCLUSIONS: Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.

Adolescent↗
PubMed2006

Nurses' perceptions of their documentation experiences in a computerized nursing care planning system.

AIM: To explore how the content design of a computerized nursing care plan affects nurses' perceptions of their documentation experience, specifically in making care plans. BACKGROUND: Nurses' attitudes towards and experiences of computer use in daily practice have been studied. However, no studies have examined how using a computerized nursing care planning system affects nurses' perceptions of the documentation process. METHODS: A descriptive, exploratory qualitative approach was used to conduct one-on-one, in-depth interviews with 20 nurses. The major interview question was, 'What do you think the content of the computerized care plan provided in making care plans?' Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process. FINDINGS: Nurses generally viewed the content of the computerized nursing care planning system as a reference to aid memory, a learning tool for patient care, and a vehicle for applying judgement to modify care plan content. CONCLUSIONS: Although computer technology is designed to streamline nurses' work, using a computerized care plan system can also enhance their knowledge, experience and judgement of descriptions of patient problems and care strategies. Thus, the effects of using technology on documentation behaviours or patterns may deserve further exploration. RELEVANCE TO CLINICAL PRACTICE: While computerized documentation systems have been used widely in patient care, little attention has been given to how the design of care plan content affects the documentation process. Electronic documentation systems can introduce nurses to new skills and knowledge that may improve care quality.

Adult↗
PubMed2004

Nursing documentation in nursing homes--state-of-the-art and implications for quality improvement.

This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients' (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients' needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n=332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients' independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients' functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.

Aged↗
PubMed2000

Emergency medicine resident documentation: results of the 1999 american board of emergency medicine in-training examination survey.

OBJECTIVES: To assess how emergency medicine (EM) residents perform medical record documentation, and how well they comply with Health Care Financing Administration (HCFA) Medicare charting guidelines. In addition, the study investigated their abilities and confidence with billing and coding of patient care visits and procedures performed in the emergency department (ED). Finally, the study assessed their exposure to both online faculty instruction and formal didactic experience with this component of their curriculum. METHODS: A survey was conducted consisting of closed-ended questions investigating medical record documentation in the ED. The survey was distributed to all EM residents, EM-internal medicine, and EM-pediatrics residents taking the 1999 American Board of Emergency Medicine (ABEM) In-Training examination. Five EM residents and the Society for Academic Emergency Medicine (SAEM) board of directors prevalidated the survey. Summary statistics were calculated and resident levels were compared for each question using either chi-square or Fisher's exact test. Alpha was 0.05 for all comparisons. RESULTS: Completed surveys were returned from 88.5% of the respondents. A small minority of the residents code their own charts (6%). Patient encounters are most frequently documented on free-form handwritten charts (38%), and a total of 76% of the respondents reported using handwritten forms as a portion of the patient's final chart. Twenty-nine percent reported delays of more than 30 minutes to access medical record information for a patient evaluated in their ED within the previous 72 hours. Twenty-five percent "never" record their supervising faculty's involvement in patient care, and another 25% record that information "1-25%" of the time. Seventy-nine percent are "never" or "rarely" requested by their faculty to clarify or add to medical records for billing purposes. Only 4% of the EM residents were "extremely confident" in their ability to perform billing and coding, and more than 80% reported not knowing the physician charges for services or procedures performed in the ED. CONCLUSIONS: The handwritten chart is the most widely used method of patient care documentation, either entirely or as a component of a templated chart. Most EM residents do not document their faculty's participation in the care of patients. This could lead to overestimation of faculty noncompliance with HCFA billing guidelines. Emergency medicine residents are not confident in their knowledge of medical record documentation and coding procedures, nor of charges for services rendered in the ED.

Adult↗