533 research outputs found

    The Development Of The Electronic Nursing Record System (ENRS) In The Hospital Setting: An Integrative Literature Review

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    In Indonesian hospitals, particularly in South Sulawesi Province, one of the activities that needs improvement by design is that of nursing records. This vital task is not completed due mainly to the fact that, incredibly, no model has been implemented to date mainly because of financial constraints and the overall lack of nurses’ computer literacy within the health services area in Indonesia. Although copious nursing recordkeeping is standard practice abroad, this vital task is not the norm in our area. Thus, the aim of this integrative literature review was to investigate the development of the electronic nursing record system (ENRS) in hospital settings across different countries and its effects on the care process and care outcomes. The results of this review showed that ENRS has been used widely in other developed countries and has benefited nurses and other healthcare providers. Hence, the findings of this review can be used by hospital policymakers in other developing countries, where the ENRS have not been implemented yet, as the evidence to consider the use of the ENRS.

    Development and Validation of a Computerized Assessment Form to Support Nursing Diagnosis

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    PURPOSE: Describe the development and validation of the Nursing Assessment Form (NAF), within a clinical nursing information system, to support nurses in the identification of nursing diagnoses. METHODS: Content validity and consensus on NAF contents were established using a panel of experts in nursing diagnosis and Delphi rounds. FINDINGS: Expert consensus was achieved to validate an instrument to support nurses in the process of nursing diagnoses identification. CONCLUSIONS: The use of the NAF can help nurses in diagnostic reasoning, facilitating the identification of the more suitable nursing diagnoses, and provide a basis for the best nursing interventions and outcomes. IMPLICATIONS FOR NURSING PRACTICE: The use of computerized decision support can improve the implementation of standardized terminology and the accuracy of nursing diagnosis

    The interplay between global standards and local practice in nursing

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    Submitted manuscript version. Published version available at https://doi.org/10.1016/j.ijmedinf.2013.02.005.Purpose: The paper assesses the extent, form, and transformation of global nursing classifications (NANDA) in a nursing practice during a period of 5 years. Method: A longitudinal case study was used to trace implementation, adoption and use of nursing classifications as an integral part of an electronic nursing module. A mixed method of data collection was used, including semi-structured interviews, observation and document analysis. Results: A surprisingly high proportion of nursing diagnoses was consistent with the global standard, in spite of a gradual increase of user-generated concepts. This is elaborated more thoroughly through a co-constructing perspective, emphasizing how the global standard and the practice mutually shaped each other over several years. Conclusion: Standardization is an iterative process that is performed in close relationship with practice. The mutual interrelation between formal classifications (NANDA) and local practices are co-constructed in a dynamic interplay that evolves over time. In such a process, the use of local classifications and local strategies can be a means to bridge the gap between these two extreme points. Highlights: ► Extensive use of standardized classification after implementation of electronic care plan. ► Local classifications evolved during long-term use. ► Co-construction of classifications was used to bridge the gap between global classifications and local needs

    ІНФОРМАЦІЙНІ МОДЕЛІ ЗАГАЛЬНОГО ДОГЛЯДУ ЗА ХВОРИМИ З ПІДТРИМКОЮ АЛГОРИТМІВ ПРИЙНЯТТЯ РІШЕНЬ НА ОСНОВІ КЛАСИФІКАТОРА ICNP

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    The paper presents information models of the nursing process through a conceptual presentation, including assessments of the patient's overall condition (nursing interviews, physical assessment, measurement, documentation analysis), nursing diagnosis, nursing care planning, determination of expected results, nursing manipulation, care plan implementation and care results evaluation. Particular attention is drawn to the possibility of using international terminology in describing nursing practices. Analysis of solutions is carried out using the terminology of decision trees.В работе представлены информационные модели процесса ухода за больными путем концептуального представления, включающие оценки состояния пациента в целостном измерении (медсестринское интервью, физикальное обследование, измерение, анализ документации), медсестринский диагноз, планирование медсестринского ухода, определение ожидаемых результатов, медсетринских манипуляций, имплементацию плана ухода и эвалуацию результатов ухода. Особое внимание обращается на возможность использования международной терминологии в описании медсестринской практики. Анализ решений проводится с использованием терминологии деревьев решений.У роботі представлено інформаційні моделі процесу догляду за пацієнтами шляхом концептуального представлення, що включають оцінювання стану пацієнта в цілісному вимірі (медсестринське інтерв'ю, фізикальне дослідження, обстеження, вимірювання, аналіз документації), медсестринський діагноз, планування медсестринського догляду, визначення очікуваних результатів, медсестринських маніпуляцій, імплементацію плану догляду та евалу-ацію результатів догляду. Особлива увага звертається на можливості використання міжнародної термінології в описі медсестринської практики. Аналіз рішень проводиться з використанням термінології дерев рішень

    Upravljanje dokumentacijom zdravstvene njege u bolničkim uvjetima

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    Healthcare documentation or nursing documentation as often used in practice is the name of an indispensable part of a patient’s medical documentation, and documentation is an integral part of a nurse’s daily work. Documenting health care in the hospital means recording data on all procedures performed, during the entire health care process for the individual, all for the purpose of systematic monitoring, planning and evaluation of the quality of health care. Nursing documentation serves as a means of communication between the team and is of great importance for the quality and continuity of health care. AIMS: 1 - To determine the existence of health care documentation in hospital health care institutions; 2 - Examine the importance and purpose of documenting health care among nurses-medical technicians; 3 - Examine the practice of nurses-medical technicians in the process of administering health care; 4 - Present quality indicators that are monitored and analyzed through health care documentation; 5 - Compare the obtained results in two examined areas. METHODS: This research was conducted in two geographically separate areas of Sarajevo and Travnik. The study involved 210 respondents, 147 nurses-technicians employed at the Clinical Center of the University of Sarajevo and 63 nurses-technicians employed at the General Hospital in Travnik. Data collection for research was carried out by exploratory and descriptive method. An original authorized questionnaire was used for the descriptive research. The questionnaire was made available to respondents in the electronic form trough Google Forms. The anonymity of the respondents was fully guaranteed. The survey was conducted in the period from July 15- August 15, 2019. RESULTS: At the Clinical Center of the University of Sarajevo (CCU), 98% of respondents use health care documentation forms on a daily basis, and at the General Hospital Travnik 77.8% of respondents. In CCU Sarajevo, respondents use more standardized forms of health care documentation, 97.6%, compared to respondents in the General Hospital Travnik, where the documenting is carries out in nursing records, 74.6%. 68% of respondents at CCU Sarajevo believe that documentation contributes to the evaluation of nursing services, while only 19% of re-spondents at General Hospital Travnik believe the same. As the most common shortcomings, the respondents state the lack of computer technology in the department in 74.3%, then adequate premises for document administration in 37.6%, the lack of forms in printed form in 32.1% and 6 or 2.3% respondents did not answer this question. In both institutions, the biggest shortcoming is the problem of computer equipment in the department, in 70.7% in CCU Sarajevo and 82.5% in General Hospital Travnik. CONCLUSIONS: The research found that over 95% of respondents use standardized health care processes in their daily practice, document health care, know the basic purpose and monitor health care indicators. More than 90% of respondents in both study groups use health care documentation to plan health care and monitor its outcomes. More than half of respondents in both study groups stated that documenting health care is a problem because it consumes a lot of time. A larger number of respondents from both groups, as many as 30%, state that they do not use the data from the health care documentation for any purpose. The lack of workers in the health care process, insufficient knowledge of information technologies, and the lack of an information system represent an aggravating circumstance in documenting the health care process.Dokumentacija zdravstvene njege ili sestrinska dokumentacija, kako se često naziva u praksi, neizostavan je dio medicinske dokumentacije pacijenta, a dokumentiranje je sastavni dio svakodnevnoga sestrinskog posla. Dokumentiranje zdravstvene njege u bolnici podrazumijeva zapisivanje podataka o svim provedenim postupcima tijekom cjelokupnog procesa zdravstvene njege za pojedinca, a sve u svrhu sustavnog praćenja stanja te planiranja i vrednovanja kvaliteta zdravstvene njege. Sestrinska dokumentacija služi kao sredstvo komunikacije između tima i od velike je važnosti za kvalitetu i kontinuitet zdravstvene njege. CILJEVI RADA: 1. Utvrditi postojanje dokumentacije zdravstvene njege u bolničkim zdravstvenim ustanovama. 2. Ispitati praksu medicinskih sestara/tehničara u procesu administriranja zdravstvene njege. 3. Prikazati indikatore kvalitete koji se prate i analiziraju putem dokumentacije zdravstvene njege. 4. Komparirati dobivene rezultate u dva ispitivana područja. METODE RADA: Ovo istraživanje provedeno je na dva geografski odvojena područja, u Sarajevu i Travniku. U istraživanju je sudjelovalo 210 ispitanika, i to 147 medicinskih sestara/tehničara zaposlenih u Kliničkom centru Univerziteta u Sarajevu i 63 medicinske sestre / medicinska tehničara zaposlena u Općoj bolnici u Travniku. Prikupljanje podataka za istraživanje provedeno je deskriptivnom metodom. Za deskriptivno istraživanje primijenjen je originalni autorski upitnik. Upitnik je ispitanicima bio dostupan u elektroničkom obliku u internetskoj aplikaciji Google Forms. Anonimnost ispitanika bila je u potpunosti zajamčena. Istraživanje je provedeno u periodu od 15. srpnja do 15. kolovoza 2019. REZULTATI ISTRAŽIVANJA:U Kliničkom centru Univerziteta u Sarajevu 98 % ispitanika svakodnevno upotrebljava obrasce dokumentacije zdravstvene njege, a u Općoj bolnici Travnik 77,8 % ispitanika. U KCU-u Sarajevo ispitanici više upotrebljavaju standardizirane obrasce dokumentacije zdravstvene njege, i to 97,6 %, u odnosu na ispitanike u Općoj bolnici u Travniku, gdje se dokumentiranje vrši u sestrinske evidencijske bilježnice, i to 74,6 %. 68 % ispitanika u KCU-u Sarajevo smatra da dokumentiranje pridonosi vrednovanju sestrinskih usluga, dok to smatra samo 19 % ispitanika iz Opće bolnice Travnik. Kao najčešće nedostatke ispitanici navode nedostatak računalne tehnike na odjelu (74,3 %), zatim neadekvatne prostorije za administriranje dokumentacije (37,6 %) te nedostatak obrazaca u tiskanom obliku (32,1 %), a na ovo pitanje nije odgovorilo šest ili 2,3 % ispitanika.U obje ustanove kao najveći nedostatak navode problem računalne opreme na odjelu, i to 70,7 % u KCU-u Sarajevo i 82,5 % u OB-u Travnik. ZAKLJUČCI: Istraživanjem je utvrđeno da više od 95 % ispitanika u svakodnevnoj praksi primjenjuje standardizirane procese zdravstvene njege, dokumentira zdravstvenu njegu, poznaje osnovnu svrhu i prati indikatore zdravstvene njege. Više od 90 % ispitanika u obje ispitivane skupine dokumentacijom zdravstvene njege kori-sti se za planiranje zdravstvene njege i praćenje njezinih ishoda.Više od polovine ispitanika u obje ispitivane skupine navelo je da im dokumentiranje zdravstvene njege predstavlja problem jer im oduzima mnogo vremena u radu. Veći broj ispitanika obje ispitivane skupine, čak 30 %, navodi da se podacima iz dokumentacije zdravstvene njege ne koriste ni u kakve svrhe. Nedostatak izvršitelja procesa zdravstvene njege, nedovoljno znanje o informacijskim tehnologijama te nepostojanje informacijskog sustava predstavlja otežavajuću okolnost u dokumentiranju procesa zdravstvene njege

    Optimalisasi Penegakan Diagnosis Keperawatan Sesuai Standar Asuhan Keperawatan di Rumah Sakit X

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    This study aims to analyze the enforcement of nursing diagnoses according to the Nursing Care Standards of X Hospital Jakarta. The research method uses a case study approach with interviews, document review and observation, and performs problem analysis using fishbone analysis. The results showed that the enforcement of nursing diagnoses in accordance with the Standards of Nursing Care was not optimal, so that it had an impact on the quality of care and its documentation. Nursing diagnoses that are in accordance with Nursing Care Standards are 48.6%. Lack of supervision from managers, assessments using personal assumptions and the standard of writing diagnoses in the local Hospital Information System (SIRS) has not been facilitated. Through strengthening the directing function with SAK media innovation, there was an increase in writing nursing diagnoses according to SAK to 62.3%. In conclusion, optimizing the enforcement of nursing diagnoses in accordance with Nursing Care Standards can be implemented with SAK media innovations (Softfiles on the Google Form Platform and flipcharts) which are given to implementing nurses at X Hospital.   Keywords: Diagnosis, Nursing Documentation, Quality, Nursing Care Standard
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