Standardized Nursing Data and the Oncology Nurse.

Oncology nurses are experts in conducting comprehensive assessments of symptoms and patient responses to treatments, but documentation in electronic health records frequently results in data that cannot be readily shared or compared because of a lack of standardization of the terms. Standardized nursing terminology can enhance communication among nurses and between nurses and other members of the healthcare team. It can improve care coordination and may enable nurses to capture and make visible the unique, holistic perspective that they provide to patient care. Standardization also is important for large-scale data aggregation, which will enable healthcare teams to learn about particular subsets of patients so that care can be tailored to individual characteristics and responses.

Registros enfermeros. Contribución a la seguridad del paciente y a la visualización de la disciplina enfermera / Nursing records. Contribution to the security of patient and visualizing of the discipline of nursing

Los registros enfermeros conforman la historia de enfermería de un paciente con el objetivo de dejar constancia de la atención prestada y de la evolución de la persona desde la mirada holística que identifica la profesión. Estos registros tienen un contexto legal, profesional y de seguridad que deben cumplir. También a través de la escritura se puede inferir la visión que de la profesión tiene el profesional/escritor. En este artículo se analizan algunas expresiones extraídas de registros enfermeros de unidades de cuidados paliativos tomando como referencia los elementos contextuales nombrados. Se concluye que se debería prestar más atención a esta actividad, que es una obligación profesional y un derecho del paciente, para dotar a los registros enfermeros de información objetiva, clara, sin ambigüedades ni interpretaciones erróneas, y que refleje la aportación específica de la enfermería a la sociedad (AU)

The nursing records conform the clinical history of a patient with the aim to bring evidence of care provided by professional as well as to bring evidence of evolution of a person from a holistic point of view that identifies the profession. These records have a legal, professional and security contexts that ought to be fulfilled. In addition, with help of record keeping it is possible to infer a vision of the profession that was transmitted by the author. This article discusses the qualitative data based on various expressions extracted from the nursing records of palliative care units, taking as a reference the contextual elements that were named above. It concludes that it’s important to give more attention to this activity as it presents a professional obligation and belongs to patient’s rights. The current research stresses the importance to have the nursing records updated with the objective information, clear, without ambiguities or misinterpretations, and which can evidence the specific contribution of nursing to the society (AU)

Impact of primary care management on nursing documentation.

AIM: The aim was to investigate whether perceptions of electronic nursing documentation and its performance differed because of primary health care management. BACKGROUND: Success in leading people depends on the manager's personality, the context and the people who are led. Close proximity to clinical work, with manager and personnel sharing the same profession, promotes the authority to carry out changes. METHODS: This study comprised a postal questionnaire to district nurses and an audit of nursing records from two primary health care organizations, one with a uniprofessional (nursing) organization, and one with multidisciplinary health care centres with general practitioners and/or another profession as managers. RESULTS: Uniprofessional nurse management increased district nurses' positive perceptions of nursing documentation but did not affect documentation performance, which was inadequate regardless of management type. CONCLUSIONS: Positive perceptions of nursing documentation are bases for further development to a nursing documentation including a holistic view of the patient.

[Comment about the policy statement of the MDS. A position statement of the assessment group of the University Witten/Herdecke with regard to nursing documentation]. / Kommentar zur Grundsatzstellungnahme "Pflegeprozess und Dokumentation" des MDS. Positionspapier der Assessmentgruppe, Universität Witten/Herdecke, zur Pflegedokumentation.

In 2005 the Medical Advisory Service of Social Health Insurance (MDS) in Germany published a policy statement with regard to the nursing process and documentation. According to the intention of the association, this statement should be considered as recommendations which are able to improve nursing practice and to contribute to streamlining of bureaucracy in nursing care. Recognising the broad impact of this publication on nursing institutions, a working group on nursing assessment of the University Witten/Herdecke conducted a critical review of the statement. Significant criteria for evaluation were the primary role of nursing documentation, quality requirements for the documentation as well as recent scientific results concerning the implementation of nursing process and assessment-based nursing diagnoses. The review revealed that the statement lacks of a clear rationale and its content appears to be merely research-based. Therefore it has to be questioned if the publication will accomplish the claimed effects. In fact, future quality criteria for health care are to be developed independently on the basis of scientific results and in consideration of the experiences of all concerned social groups.

Finding midwifery in administrative data systems.

Nurse-midwifery has accomplished remarkable clinical, policy, and political achievements using specially-collected data. Today, midwifery practice data can be found in existing administrative data systems: birth registration, hospital data depositories, and claims files. Issues in finding midwifery as practice and profession in these data systems are discussed. Improving the integrity of data that reveal midwives as caregivers should be a priority.

Mapping of nursing records into the NIC and the ICNP in a Korean oriental-medicine hospital.

This study uses mapping methodology to examine the applicability of the Nursing Interventions Classification and the International Classification of Nursing Practice to nursing practice in a Korean Oriental-medicine hospital. Data were collected from the nursing records of 56 stroke patients in one unit, and intervention statements were mapped into NIC and ICNP. Of 147 unique nursing intervention statements extracted, 136 (92.52%) could be mapped into NIC and 99 (67.35%) statements could be completely mapped into ICNP. Using mapping methodology, this study validates that both NIC and ICNP would be useful for documenting nursing care in a Korean hospital, but it also identifies additional concepts that need to be represented in both of these standardized nursing languages. It is recommended that nurses be more careful in documenting their interventions and also that SNLs be developed further to more completely represent nursing practice.

Documenting health promotion services in community-based nursing centers.

A data-collection tool developed to document health promotion services and describe program participants was used by 7 community-based nursing centers for 12 months. Data analysis results found that a wide range of services were offered to target populations across the life span, with adults aged 60 and older being the largest group of program users.

[Analysis of nursing records in a surgical ward of a public teaching hospital]. / Análise dos registros de enfermagem em uma unidade cirúrgica de um hospital-escola público.

This article presents a systematic descriptive and retrospective study on nursing notes on patients admitted to the surgical ward of a teaching hospital in Londrina, Paraná, Brazil, which aimed at their systematic analisys. Results show that the largest number of notes was made during the morning shift, and most of them were made by nurse auxiliaries. As to basic needs, psychobiological records were the most frequent, whereas there no psychospiritual records were found. It was concluded that nursing notes must be improved, and take into account integral care of patients.