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Availability of Nursing Records in The General Medical and Surgical

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Availability of Nursing Records in The General Medical and Surgical Powered By Docstoc
					Quality Patient Care
   Is Frequently Measured
      Through Analysis of




The Communication Systems
 Prevalent in Nursing Units.
 Accreditation Agencies
     Frequently Use


 Nursing             Documentation
 Records          of Nursing Activities

             As

Objective Measures of Quality of
         Patient Care.
Proper Documentation Tools
Are Essential to Help Nurses
  in Better Communication
             And
            Hence
Refers to the Preparation
  and Maintenance of
Records That Describe a
      Patient Care.
In Nursing Can Be in Form of
           Either


Written      or      Oral


Documentation of Nursing Care
..Where As        Recording
                    Involves
• Written documentation of the
  pertinent.
• Significant aspects of all facts of daily
  care.
• Status of the patient’s condition
   throughout that time period
 While..   Reporting
              Is
     A Form of Oral
  Documentation That
Summarizes the Care and
   the Patient Status
Both Forms of Documentation
Facilitate Continuity of Care
 As
Reporting
   Allows Rapid Sharing of
Patient’s Data That Assure the
Use of Current Information in
   Clinical Decision Making
   While

Recording

Provides a Permanent and
  Complete Document of
 Patient’s Care Activities.
In General



It Has Been Observed That
   Few Nurses Give Little
Attention to Documentation
            Tools
  The Communication System in
Patient’s Units That Assess Nursing
  Personnel Learning Needs for
Documentation and Communication
            May Help in



  Identifying the Needs for
  Developing a Manual That
Provide Directions and Guide
 Lines for Nursing Personnel
 And this is to

• Upgrade Their Communication
 Skills
• Improve Documentation

• Improve Their Quality of Patient
 Care
 Assess availability of different
nursing records and reports currently in
use in the General Medical & Surgical
units of Alexandria Main University
Hospital and pattern of Documentation.


 Assess nurses opinions regarding
pattern of communication in such
patient care units.
 Assess Nurses’ Knowledge and
Learning   Needs  for   Effective
Communication and Documentation
System


 Develop a Manual to Meet The
Identified Needs
• The study was conducted at the
general medical and surgical units
of the Alexandria Main University
Hospital.

• Two general medical and two
general   surgical     units   were
randomly selected for the study.
• The study covered all nurses who
were available in the selected units
at the time of the study.
• A representative sample of medical
records of patients admitted at the
selected units during the data
collection period that extended over
one month.

•Forty    medical   records    were
selected, 10 from each unit.

•The criterion for selection was that
the patient had to be hospitalized
for at least one week .
A) Checklist for Auditing
Patient’s     Record      Was
Developed by the Researcher
Based on the Review of Current
Relevant Literature
   It is used to collect data
           regarding:
 1. Availability of nursing records and
 reports used by nursing personnel in
 the unit.
2. Pattern of documentation. A 3-point
scale was used to judge the adequacy of
documentation.
 2 stands for   1 stands for   0 stands for No
  Adequate      Incomplete     Documentation
B) Another Checklist Was
Developed to Assess Nurses’
Opinion Regarding Pattern of
Communication Prevailing in
Their Units.
C) A Questionnaire Was Developed to
Assess Nurses’ Knowledge and Learning
Needs Regarding Communication Process,
Principles of Proper Documentation,
Recording and Reporting Methods and
Their Importance and Benefits.
A 3-point scale was used to judge the
adequacy of documentation.

 2 stands for   1 stands for   0 stands for No
  Adequate      Incomplete     Documentation
Based on the identified needs, a
Manual was developed. The contents
of the Manual were developed with
the help of current literature, taking
into consideration the educational
background of the nursing staff and
the general principle of adult
education.
               Data Were Collected
               Through:

1.   Concurrent review of the
patients’ medical records as
well as reports used by nursing
personnel in the selected units
to    assess    availability of
different types of nursing
records and reports and pattern
of documentation.
                 ??????


2.   Questionnaire interview
with each individual nurse
working at the selected units to
assess the nurses’ knowledge
and learning needs regarding
documentation process and
system.
3. The Content Validity of the
Developed      Manual       Was
Assessed by a Jury of Expert
Nurse Educators and Then
Administered to the Head
Nurses of the Selected Units.
4.  Educational Sessions
Were Conducted With
the Head Nurses to
Clarify the Purposes of
the Manual and How It
Can Be Applied in Their
Clinical Areas.
Availability of Nursing Records in The
 General Medical and Surgical Units

A- Records                  Available
                            Not Available



             71.42       28.57
              %           %
 For Example
•Plan of Care Forms
• Medical Order    
• Nursing Care Plan 
• Teaching Plan         25%

• Kardex Form          75%
  For Example
• Other Clinical Nursing Forms:
• Vital Signs Record   
• Fluid Balance Record 
• Narcotic Record              50%

• Diabetes Record               50%
  (Insulin Chart)      
• Coagulation Record   
• Nursing Medication Record 
Availability of Nursing Records in The
 General Medical and Surgical Units
B- Reports                  Available
                            Not Available




             75.00       25.00
              %           %
                                                     10%
                                                           20%
                                                                 30%
                                                                       40%
                                                                             50%
                                                                                   60%
                                                                                         70%
                                                                                               80%
                                                                                                     90%
                                                                                                           100%




                                                0%
                           Dark ink writing



                     Legible handwriting


           Patient's identef ication


             No spelling mistakes


                                   Language



                  Using Correct f orm


      All data entries timed &
                dated

                                 Standrdized
                                 observ ation


                          Correcting errors


                             No duplication


                 Av oid blank spaces


            Signing in f ull name &
                   Position
                          None
                                                                                                                  Adequacy of Documentation of Nursing forms at Medical Surgical Units




Adequate
             Inadequate
Knowledge
                  0%
                       10%
                             20%
                                   30%
                                         40%
                                               50%
                                                     60%
                                                           70%
                                                                 80%
                                                                       90%
                                                                             100%




Learning Needs
 Importance of
Communication



 Elements of
Communication



 Channels of
Communication



  Types of
Communication



Communication
  Barriers



How to improve
Communication



Conference as a
mean of comm.
                                                                                    Learning Needs Regarding Communication Process.
                                                                                    Percent Distribution of Nurses’ Knowledge and Their
  Percent Distribution of Nurses’ Knowledge and Their
         Learning Needs Regarding Reporting.
           100%

            90%

            80%

            70%

            60%

            50%

            40%

            30%

            20%

            10%

             0%




                                                                       Purpose of each
                  Definition of




                                                                                         using each report
                                  Basic guidelnes




                                                    Types of nursing
                   Reporting




                                                                        nursing report




                                                                                           Proper way of
                                    of reporting




                                                        reports




Learning Needs
Knowledge
Percent Distribution of Nurses’ Knowledge and Their
       Learning Needs Regarding Recording.

            100%

             90%

             80%

             70%

             60%

             50%

             40%

             30%

             20%

             10%

                 0%
                                      Basic guidelnes of




                                                           responsibility for
                      Definition of




                                                           patients records
                      Recording




                                         recording




                                                               Nurses'
Learning Needs
Knowledge
A. Communication with Physicians:
1. Physician’s Orders
• Physician orders are Clear

• Abbreviations used by physicians are known
 • Type                90
    • Written orders   80
                       70
    • Oral orders      60
                       50
                       40
                       30
                       20
                       10
                        0




                                                         Written/Oral
                            Orders are




                                         Abbreviations
                            Physician




                                          Physicians
                                          are known
                              Clear




                                           used by




                                                            Type
• Written Orders :
     a. in patients medical records   Written
                                      Oral
     b. in other forms
                             90%




                               10%


• Oral Orders.
A. Communication with Physicians:
 1. Discussion of Patients Condition

 • During Clinical Rounds

• During Daily Conference              During Daily
                                       Conference
                                       During Clinical
                                       rounds

                                 80%



               90%
B- Communication Among Nurses
   1. Shift Reports                                                                                Oral
                                                                                                 Reporting


  80%                                              Both
                                                      12                                            50
  70%                                                            Written


  60%
                                                           12   Reporting




  50%                                                                                                        Oral Reporting
                                                                                                             Written Reporting
                                                                                                             Both
  40%

  30%

  20%

  10%

  0%




                                                                                                                Shift Report
                               Reports are clear




                                                                            Time for Reporting
          Condition on every
          Reporting Patients




                                Written Shifts




                                                                                is enough
                  shift
  2. Assigning Duties

• Person Responsible for Assigning
Duties.

                              74%
 Head Nurse

                        26%




Senior Staff Nurse                  Head Nurse
                                    Assistant head nurse
• Type of Assigning Duties

 Oral 80%

Written 0%
                             80%




                   20%




Not Done                           Oral
                                   Not Done
C- Interdepartmental Communication:


  Special Records
                              74%




                       26%




                                      Special Records

 Phone Calls                          Phone Calls
Documentation
      Manual


    Improve Nurses’
   Documentation Skills


Enhance Quality Patient Care
Based on the Findings
  of the Study, The
      Following
  Recommendations
 Would be Suggested:
 1
The Developed Manual should be
used on an ongoing basis.
It should be administered to
each newly employed nurse to:
   • Refresh her knowledge.
   • Develop an insight of her role
   regarding the documentation
   system and its importance.
 2
To Help Nurses to apply the
developed manual, the different
forms of nursing records and
reports suggested in the manual
should be made available to
nurses by the hospital or health
authority and be kept as a
permanent data source.
 3
Proper Supervision must be
continuously performed by the
head nurse to ensure that nurses
utilize   the    documentation
system    in   a   proper   and
consistent way.
 4
Physicians must take into their
consideration    reports   and
records written by nurses to
encourage     them    to   use
documentation of the nurses’
forms.
 5

There should be strict hospital
and rules to control nurses
negligence of recording and
reporting.
THANK
  S

				
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posted:12/5/2012
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