Using standardized nursing data for knowledge generation - Ward level analysis of point of care nursing documentation.

BACKGROUND: Standardized nursing terminology is a prerequisite for describing nursing care processes and generating knowledge for decision-making and management. The structure of the Finnish Care Classification (FinCC) facilitates documentation of nationally agreed core nursing data: nursing diagnoses, interventions, and outcomes. PURPOSE: To analyze the use of FinCC to assess patient care needs (nursing diagnoses), care implementations (interventions) and evaluation of the outcomes of nursing care in electronic health records. METHODS AND MATERIALS: The descriptive study applied purposeful sampling of nursing data from nursing data repositories in three surgical wards in tertiary and secondary care hospitals. The aggregated, anonymous ward level data from a six-month period was analyzed to show distributions within frequencies and means of component, main and subcategory level use of FinCC in the three hospitals. RESULTS: Each of the three levels of the FinCC (component, main and subcategory) were used for recording nursing care. In all hospitals, the three most used diagnosis components covered about one third of the use of all the 17 components. The five most used intervention components cover about one third of the components. The most often used components for diagnoses and interventions were Coordination of care and follow-up care, Pain Management, Activities of daily living and independence and Medication. The prevalence of different components and the main and subcategory level usage for both diagnoses and interventions varied between the hospitals. CONCLUSION: Standardized point-of-care nursing data makes patients' daily nursing care transparent. Structured, standardized, and point-of-care nursing data can be utilized to generate new knowledge of nursing care processes and nursing care practice at ward level.

Standardized Nursing Documentation Supports Evidence-Based Nursing Management.

Nursing documentation is crucial to high quality, effective and safe nursing care. According to earlier studies nursing documentation practices vary and nursing classifications used in electronic patient records (EPR) are not yet standardized internationally nor nationally. A unified national model for documenting patient care improves information flow in nursing practice, management, research and development toward evidence-based nursing care. Nursing documentation quality, accuracy and development requires follow-up and evaluation. An audit instrument is used in the Kuopio University Hospital (KUH) when evaluating nursing documentation. The results of the auditing process suggest that the national nursing documentation model fulfills nurses' expectations of electronic tools, facilitating their important documentation duty. This paper discusses the importance of using information about nursing documentation and how we can take advantage of structural information in evidence-based nursing management.

Milestones and Experiences of Standardized Documentation.

The purpose of this panel is to discuss milestones and experiences of a standardized nursing terminology for the documentation of nursing practice using Clinical Care Classification as an example. The aim is to describe the value of using the CCC as the standardized nursing terminology and framework for the multidisciplinary care plans and how its interoperability with SNOMED CT, LOINC, and other required terminologies can be used for the electronic health record systems. Further the aim is to discuss the advantages a multidisciplinary documentation system and how it impacts on nursing practice, management, and research as well as highlight the monitoring of nursing documentation. The target audience will enrich their understanding about the possibilities that a standardized multidisciplinary documentation is critical for future data analyses and datamining highlighting nursing practices.

Nursing audit as a method for developing nursing care and ensuring patient safety.

Nursing documentation is crucial to high quality, good and safe nursing care. According to earlier studies nursing documentation varies and the nursing classifications used in electronic patient records (EPR) is not yet stable internationally nor nationally. Legislation on patient records varies between countries, but they should contain accurate, high quality information for assessing, planning and delivering care. A unified national model for documenting patient care would improve information flow, management between multidisciplinary care teams and patient safety. Nursing documentation quality, accuracy and development needs can be monitored through an auditing instrument developed for the national documentation model. The results of the auditing process in one university hospital suggest that the national nursing documentation model fulfills nurses' expectations of electronic tools, facilitating their important documentation duty. This paper discusses the importance of auditing nursing documentation and especially of giving feedback after the implementation of a new means of documentation, to monitor the progress of documentation and further improve nursing documentation.

Whose Voices are Heard in Patient Safety Incident Reports?

Patient safety incident reporting systems are used to monitor adverse events, generate information for risk management and to improve patient safety. A number of electronic reporting systems have been developed, but their data elements appear relatively similar. An inductive data analysis was carried out to find out especially what is the content of descriptions of contributing factors of adverse events. The data consisted of incident reports entered in a hospital based reporting system in the years 2008-2010. Overall, 82 reports of 785 contained free text information about patients' and relatives' involvement in the events reported by staff. We found that patients themselves noticed almost half of these incidents. Of the incidents they noticed, most resulted in moderate harm.