Evolution of electronic nursing documentation quality in cardiac care – A retrospective study in a Hospital District in Finland
Shakya, Arjina (2023-03-30)
Evolution of electronic nursing documentation quality in cardiac care – A retrospective study in a Hospital District in Finland
(30.03.2023)
Julkaisu on tekijänoikeussäännösten alainen. Teosta voi lukea ja tulostaa henkilökohtaista käyttöä varten. Käyttö kaupallisiin tarkoituksiin on kielletty.
suljettu
Julkaisun pysyvä osoite on:
https://urn.fi/URN:NBN:fi-fe2023050239969
https://urn.fi/URN:NBN:fi-fe2023050239969
Tiivistelmä
Abstract
Nursing documentation is the recording of the information related to the nursing care provided to the patients. A good nursing documentation is an imperative nursing responsibility. The principle of a good record is that the documentation is done on time or immediately after the completion of the nursing task. In recent days, there is a huge transformation of paper-based records into the electronic health record system. Electronic nursing documentation plays an important role in ensuring patient safety and good quality of care. Therefore, evaluating the electronic nursing documentation is very important for the continuation of good quality of care and for providing evidence of safe and high-quality care. The purpose of this study is to describe the evolution of nursing documentation of cardiac patients in a hospital district in Finland and compare how the quality has changed over time.
A retrospective record review was used as the research design. Out of a total of 450 patients’ electronic nursing documentation, 180 patients’ electronic nursing documentation was selected by employing a random sampling method after the pseudonymization of the nurses’ documentation. The retrospective audit of the 180 patients’ documents was done using the Nursing and Midwifery Content Audit Tool (NMCAT).
The audit result showed the evolution of electronic nursing documentation quality. The documentation quality has improved for 15 various criteria of the NMCAT. The results showed an increasing trend in the quality of electronic nursing documentation. A patient’s problem written as what the patient said or observed by the nurse was improved from 26.7% to 68.3%. There was remarkable progress in recording the patient status, which had improved from 13.3% to 75%. Similarly, records on providing education and psychosocial care improved from 55% to 78.3%. Fisher´s exact test determined that the p-value was less than .001 in most of the criteria of the NMCAT, which shows a significant difference.
In a nutshell, the findings of this study are indicative of the progressive evolution of electronic documentation in a hospital district in Finland. The periodic evaluation of electronic nursing documentation is necessary for monitoring the quality of care delivered to the patients. The literature review is suggestive on the provision of training the nurses for quality improvement on nursing documentation.
Keywords: Electronic nursing documentation, electronic health records, quality, evolution, evaluation
Nursing documentation is the recording of the information related to the nursing care provided to the patients. A good nursing documentation is an imperative nursing responsibility. The principle of a good record is that the documentation is done on time or immediately after the completion of the nursing task. In recent days, there is a huge transformation of paper-based records into the electronic health record system. Electronic nursing documentation plays an important role in ensuring patient safety and good quality of care. Therefore, evaluating the electronic nursing documentation is very important for the continuation of good quality of care and for providing evidence of safe and high-quality care. The purpose of this study is to describe the evolution of nursing documentation of cardiac patients in a hospital district in Finland and compare how the quality has changed over time.
A retrospective record review was used as the research design. Out of a total of 450 patients’ electronic nursing documentation, 180 patients’ electronic nursing documentation was selected by employing a random sampling method after the pseudonymization of the nurses’ documentation. The retrospective audit of the 180 patients’ documents was done using the Nursing and Midwifery Content Audit Tool (NMCAT).
The audit result showed the evolution of electronic nursing documentation quality. The documentation quality has improved for 15 various criteria of the NMCAT. The results showed an increasing trend in the quality of electronic nursing documentation. A patient’s problem written as what the patient said or observed by the nurse was improved from 26.7% to 68.3%. There was remarkable progress in recording the patient status, which had improved from 13.3% to 75%. Similarly, records on providing education and psychosocial care improved from 55% to 78.3%. Fisher´s exact test determined that the p-value was less than .001 in most of the criteria of the NMCAT, which shows a significant difference.
In a nutshell, the findings of this study are indicative of the progressive evolution of electronic documentation in a hospital district in Finland. The periodic evaluation of electronic nursing documentation is necessary for monitoring the quality of care delivered to the patients. The literature review is suggestive on the provision of training the nurses for quality improvement on nursing documentation.
Keywords: Electronic nursing documentation, electronic health records, quality, evolution, evaluation