Asta Thoroddsen, Margareta Ehnfors, Anna Ehrenberg
{"title":"Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records.","authors":"Asta Thoroddsen, Margareta Ehnfors, Anna Ehrenberg","doi":"10.1097/NCN.0b013e3182148c31","DOIUrl":"https://doi.org/10.1097/NCN.0b013e3182148c31","url":null,"abstract":"<p><p>The nursing process and standardized nursing terminologies are essential elements to structure nursing documentation in daily nursing information management. The aim of this study was to describe sustainability and whether and how standardized nursing terminologies, in handwritten versus preprinted versus computerized nursing care plans, changed the content and completeness of documented nursing care. Three audits of patient records were performed: a pretest (n = 291) before a yearlong implementation of standardized nursing terminologies in nursing care plans followed by two posttests: (1) 3 weeks after implementation of nursing terminologies (n = 299) and (2) 22 months after implementation of nursing terminologies and 8 months after implementation of a computerized system (n = 281) in a university hospital. Content and completeness of documented nursing care improved after implementation of standardized nursing terminologies. Documentation of nursing care plans, signs and symptoms, related factors, and nursing interventions increased, whereas mean number of nursing diagnoses per patient did not change between audits. Computerized nursing care plans had the biggest impact, with more variety of nursing diagnoses and increased documentation of signs and symptoms, related factors, and nursing interventions. The use of standardized nursing terminologies improved nursing content in the nursing care plans. Moreover, computerized nursing care plans, in comparison with handwritten and preprinted care plans, increased documentation completeness.</p>","PeriodicalId":520598,"journal":{"name":"Computers, informatics, nursing : CIN","volume":" ","pages":"599-607"},"PeriodicalIF":1.3,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/NCN.0b013e3182148c31","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40118323","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Source of truth: where is it in your documentation?","authors":"Catherine Whelchel, Ruth Nordquist, Dianne Koepping, Stacy Kronholm","doi":"10.1097/NCN.0b013e3182380f7a","DOIUrl":"https://doi.org/10.1097/NCN.0b013e3182380f7a","url":null,"abstract":"<p><p>In summary, a variety of documentation sources may affect reporting accuracy as well as bedside efficiency. the successful process to streamline documentation at HealthEast requires clinicians from the bedside, informatics staff, and the quality office to ensure an efficient and thoughtful implementation. As hospitals begin to address the HITECH guidelines for electronic reporting, current documentation infrastructure may provide opportunity for process improvement. Where is your source of truth?</p>","PeriodicalId":520598,"journal":{"name":"Computers, informatics, nursing : CIN","volume":" ","pages":"539-41"},"PeriodicalIF":1.3,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/NCN.0b013e3182380f7a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40113717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Improving informatics skills for clinicians, new foundation incorporates.","authors":"Christel Anderson","doi":"10.1097/01.NCN.0000407140.06532.4f","DOIUrl":"https://doi.org/10.1097/01.NCN.0000407140.06532.4f","url":null,"abstract":"","PeriodicalId":520598,"journal":{"name":"Computers, informatics, nursing : CIN","volume":" ","pages":"543"},"PeriodicalIF":1.3,"publicationDate":"2011-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/01.NCN.0000407140.06532.4f","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40113719","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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