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Articles on Documentation

1. A hospital wide nursing documentation project
By Tranter, Shelley. Australian Nursing Journal 17. 5 (Nov 2009): 34-6.
Abstract: Once the final draft was conducted there was extensive consultation with the key stakeholders including nurse unit managers, CNCs, nurse educators and senior nursing executives in addition to all members of the working group. The area policy, however, does not refer to the SAO method and there is no audit tool recommended that measures the quality of nurses' documentation in the medical record. [...] to ensure the SAO method of documenting is supported at an organisational level and the process of improving nursing documentation continues, a clinical business rule (CBR) or guideline will be written.

2. Teaching Home Care Electronic Documentation Skills to Undergraduate Nursing Students
By Nokes, Kathleen M; Aponte, Judith; Nickitas, Donna M; Mahon, Pamela Y; Rodgers, Betsy; et al. Nursing Education Perspectives 33. 2 (Mar/Apr 2012): 111-5
Abstract: Although there is general consensus that nursing students need knowledge and significant skill to document clinical findings electronically, nursing faculty face many barriers in ensuring that undergraduate students can practice on electronic health record systems (EHRS). External funding supported the development of an educational innovation through a partnership between a home care agency staff and nursing faculty. Modules were developed to teach EHRS skills using a case study of a homebound person requiring wound care and the Medicare-required OASIS documentation system. This article describes the development and implementation of the module for an upper-level baccalaureate nursing program located in New York City. Nursing faculty are being challenged to develop creative and economical solutions to expose nursing students to EHRSs in nonclinical settings. [PUBLICATION ABSTRACT]

3. Nursing Record Systems / Documentation [2011-11-19]
By García, Elena García, MSc, PhD.
Evidence Summaries - Joanna Briggs Institute. (Nov 19, 2011).
Abstract: This Evidence Summary answers the question: What information does a clinician require in regards to nursing documentation and recording systems?

4. Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care
By Kelley, Tiffany F, MS, MBA, RN; Brandon, Debra H, PhD, RN, CCNS, FAAN; Docherty, Sharron L, PhD, CPNP (AC-PC).
Journal of Nursing Scholarship 43. 2 (Jun 2011): 154-62
Abstract: Electronic health records are expected to improve the quality of care provided to hospitalized patients. For nurses, use of electronic documentation sources becomes highly relevant because this is where they obtain the majority of necessary patient information. An integrative review of the literature examined the relationship between electronic nursing documentation and the quality of care provided to hospitalized patients. Donabedian's quality framework was used to organize empirical literature for review. To date, the use of electronic nursing documentation to improve patient outcomes remains unclear. Future research should investigate the day-to-day interactions between nurses and electronic nursing documentation for the provision of quality care to hospitalized patients. The majority of U.S. hospital care units currently use paper-based nursing documentation to exchange patient information for quality care. However, by 2014, all U.S. hospitals are expected to use electronic nursing documentation on patient care units, with the anticipated benefit of improved quality. However, the extent to which electronic nursing documentation improves the quality of care to hospitalized patients remains unknown, in part due to the lack of effective comparisons with paper-based nursing documentation.

5. A Nursing-Specific Model of EPR Documentation: Organizational and Professional Requirements
By Krogh, Gunn von; Nåden, Dagfinn.
Journal of Nursing Scholarship 40. 1
(First Quarter 2008): 68-75.
Abstract: To present the Norwegian documentation KPO model (quality assurance, problem solving, and caring). To present the requirements and multiple electronic patient record (EPR)functions the model is designed to address.The model's professional substance, a conceptual framework for nursing practice is developed by examining, reorganizing, and completing existing frameworks. The model's methodology, an information management system, is developed using an expert group. Both model elements were clinically tested over a period of 1 year.
The model is designed for nursing documentation in step with statutory, organizational, and professional requirements. Complete documentation is arranged for by incorporating the Nursing Minimum Data Set. A systematic and comprehensive documentation is arranged for by establishing categories as provided in the model's framework domains. Consistent documentation is arranged for by incorporating NANDA-I Nursing Diagnoses, Nursing Intervention Classification, and Nursing Outcome Classification. The model can be used as a tool in cooperation with vendors to ensure the interests of the nursing profession is met when developing EPR solutions in healthcare. The model can provide clinicians with a framework for documentation in step with legal and organizational requirements and at the same time retain the ability to record all aspects of clinical nursing.

6. The Use of Nursing Diagnoses in Perioperative Documentation
By Junttila, Kristiina; Hupli, Maija; Salanterä, Sanna. International Journal of Nursing Terminologies and Classifications 21. 2 (Apr-Jun 2010): 57-68
Abstract: To clinically validate the nursing diagnoses of the first Finnish version of Perioperative Nursing Data Set (PNDS) by using them in perioperative documentation. Nursing diagnoses were used in documentation in four operating departments with 250 patients. In analysis, nonparametric tests were applied. While intraoperatively nursing diagnoses focused on physiological concerns, postoperatively the focus shifted to that of recovery. The findings revealed the importance of safety-related routines in perioperative care. Nursing diagnoses in the Finnish version of PNDS are sensitive in describing the rationales for perioperative care. Nursing classifications illustrate the nursing process in a structured form. Nursing diagnosis is an early step in the decision-making process that aims to achieve expected outcomes in nursing care.

Journal - Table of Contents

7. The Journal of Continuing Education in Nursing
July 2012, Volume 43, Issue 7
Editorial
7A. Our Future Is Bright
Administrative Angles
7B. Validating Clinical Competence
Clinical Updates
7C. The Final Act of Nursing Care
Teaching Tips
7D. Teaching Medical Terminology Using Word-Matching Games
CNE Article
7E. Registered Nurses’ Perspectives on the New Graduate Working in the Emergency Department or Critical Care Unit
CNE Quiz
7F. Registered Nurses’ Perspectives on the New Graduate Working in the Emergency Department or Critical Care Unit
Original Article
7G. The Use of an Advanced Medical-Surgical Course for the Retention and Professional Development of Medical-Surgical Nurses in an Acute Care Hospital
Original Article
7H. The Clinical Practice Collaborative Support Model for the Graduate Nurse
Original Article
7I. Benefits of a Unit-Based Skin Care Group
Original Article
7J. Transforming the Journey for Newly Licensed Registered Nurses

News - National

8. Wellington flu spike looming
Stuff - 6 July 2012
The winter flu is starting to take hold in Wellington with an increase in cases compared to last year. Ten hospital patients tested positive for Influenza last month, Capital and Coast District Health Board Infectious Diseases Specialist Tim Blackmore said. "The laboratory testing data for the region shows an increase in numbers compared to last year, but there has not been any sharp increase seen."
http://www.stuff.co.nz/dominion-post/news/7235018/Wellington-flu-spike-looming

9. Influenza
Ministry of Health
Influenza – or the flu – is a virus that spreads quickly from person to person. Symptoms include fever, chills, aches, runny nose, a cough and stomach upset. Immunisation is your best defence against the flu.
http://www.health.govt.nz/yourhealth-topics/diseases-and-illnesses/influenza

News - International

10. The 50-year global cover-up
The Age - Nick McKenzie and Richard Baker
SECRET files reveal the German maker of thalidomide ignored and covered up repeated warnings that its drug could damage unborn babies. Read the affidavit material containing confidential Grunenthal files - Part 1 Part 2. The Age has obtained excerpts of never-before-published files from the archives of pharmaceutical giant Grunenthal which detail explicit warnings the company received about its drug's potential to harm foetuses well before it was withdrawn from sale in late 1961.
http://www.theage.com.au/national/the-50year-global-coverup-20120725-22r5c.html

11. Working out in the middle of the working day
Calgary Herald
With the three-martini lunch gone the way of the typewriter, office workers are free to discover the healthier perks of midday movement. An active lunchtime can range from the sweaty to the serene, experts say, from a full-out cardio blast to a walk in the park. "People who want to get in a good workout over lunch hour can do simple things like go for a walk," said Dr. Cedric Bryant, chief science officer of the American Council on Exercise
http://www.calgaryherald.com/health/diet-fitness/Working+middle+working/6975135/story.html