Comparison and combination of three data sources from patient medical records to determine optimal quantification of postoperative morbidity according to the Clavien Dindo Classification and the Comprehensive Complication Index. A prospective study.

INTRODUCTION: It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC). The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report. METHODS: Observational and prospective cohort study. The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI). RESULTS: The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively. The combination of sources improved CCI agreement by 8%-40% in the overall series and 39.1-89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %-67.5% in operations of greater complexity. The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively. CONCLUSIONS: The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions.

A nursing note-aware deep neural network for predicting mortality risk after hospital discharge.

BACKGROUND: ICU readmissions and post-discharge mortality pose significant challenges. Previous studies used EHRs and machine learning models, but mostly focused on structured data. Nursing records contain crucial unstructured information, but their utilization is challenging. Natural language processing (NLP) can extract structured features from clinical text. This study proposes the Crucial Nursing Description Extractor (CNDE) to predict post-ICU discharge mortality rates and identify high-risk patients for unplanned readmission by analyzing electronic nursing records. OBJECTIVE: Developed a deep neural network (NurnaNet) with the ability to perceive nursing records, combined with a bio-clinical medicine pre-trained language model (BioClinicalBERT) to analyze the electronic health records (EHRs) in the MIMIC III dataset to predict the death of patients within six month and two year risk. DESIGN: A cohort and system development design was used. SETTING(S): Based on data extracted from MIMIC-III, a database of critically ill in the US between 2001 and 2012, the results were analyzed. PARTICIPANTS: We calculated patients' age using admission time and date of birth information from the MIMIC dataset. Patients under 18 or over 89 years old, or who died in the hospital, were excluded. We analyzed 16,973 nursing records from patients' ICU stays. METHODS: We have developed a technology called the Crucial Nursing Description Extractor (CNDE), which extracts key content from text. We use the logarithmic likelihood ratio to extract keywords and combine BioClinicalBERT. We predict the survival of discharged patients after six months and two years and evaluate the performance of the model using precision, recall, the F1-score, the receiver operating characteristic curve (ROC curve), the area under the curve (AUC), and the precision-recall curve (PR curve). RESULTS: The research findings indicate that NurnaNet achieved good F1-scores (0.67030, 0.70874) within six months and two years. Compared to using BioClinicalBERT alone, there was an improvement in performance of 2.05 % and 1.08 % for predictions within six months and two years, respectively. CONCLUSIONS: CNDE can effectively reduce long-form records and extract key content. NurnaNet has a good F1-score in analyzing the data of nursing records, which helps to identify the risk of death of patients after leaving the hospital and adjust the regular follow-up and treatment plan of relevant medical care as soon as possible.

Evaluating the validity of the nursing statements algorithmically generated based on the International Classifications of Nursing Practice for respiratory nursing care using large language models.

OBJECTIVE: This study aims to facilitate the creation of quality standardized nursing statements in South Korea's hospitals using algorithmic generation based on the International Classifications of Nursing Practice (ICNP) and evaluation through Large Language Models. MATERIALS AND METHODS: We algorithmically generated 15 972 statements related to acute respiratory care using 117 concepts and concept composition models of ICNP. Human reviewers, Generative Pre-trained Transformers 4.0 (GPT-4.0), and Bio_Clinical Bidirectional Encoder Representations from Transformers (BERT) evaluated the generated statements for validity. The evaluation by GPT-4.0 and Bio_ClinicalBERT was conducted with and without contextual information and training. RESULTS: Of the generated statements, 2207 were deemed valid by expert reviewers. GPT-4.0 showed a zero-shot  AUC of 0.857, which aggravated with contextual information. Bio_ClinicalBERT, after training, significantly improved, reaching an AUC of 0.998. CONCLUSION: Bio_ClinicalBERT effectively validates auto-generated nursing statements, offering a promising solution to enhance and streamline healthcare documentation processes.

Cuidar da pessoa em situação critica no serviço de urgência: contributos do enfermeiro especialista para a qualidade dos cuidados / Caring for the critically ill person in the emergency department: the specialist nurse's contribution to the quality of care

Este relatório de estágio surge no âmbito do curso de Mestrado em Enfermagem Médico- Cirúrgica e pretende evidenciar as experiências e atividades desenvolvidas no sentido de adquirir e desenvolver competências especializadas. A estrutura do relatório teve como linha orientadora os domínios de competências definidas para o Enfermeiro Especialista pela Ordem dos Enfermeiros, enquadradas nos domínios académicos preconizados pela Instituição de Ensino. O perfil de conhecimentos e competências do Enfermeiro Especialista na área da pessoa em situação crítica deve responder de forma competente à frágil e complexa situação clínica, sendo o seu papel suportado por um quadro de competências diferenciadas enquadradas no respeito pelo Ser Humano e pelos seus direitos inalienáveis. Focados no crescimento e desenvolvimento de competências especificas na área da pessoa em situação crítica, bem como no contributo da visão diferenciada do Enfermeiro Especialista na melhoria da qualidade dos cuidados, procuramos dar resposta aos problemas encontrados na prática clínica. Das atividades desenvolvidas destacamos a criação de um fluxograma de apoio ao enfermeiro triador no encaminhamento interno dos doentes e de um protocolo terapêutico de atuação no adulto com febre na triagem de manchester. Evidenciamos também, o investimento resiliente no desenvolvimento e implementação de um protocolo complexo, no âmbito da prestação de cuidados em contexto de urgência, ao doente em estado de agitação/agressividade que visa mitigar um problema recorrente. No domínio académico da investigação desenvolvemos um estudo qualitativo com recurso à técnica de Focus Group, com o objetivo de construir um modelo de documentação padronizado, simplificado e facilitador do registo de enfermagem que documente a atuação do enfermeiro na avaliação e intervenção ao doente, durante o transporte inter-hospitalar. As conclusões deste estudo de investigação validaram um modelo de registo sustentado numa mnemónica, uniformizadora e facilitadora dos registos de enfermagem durante o transporte inter-hospitalar do doente crítico. Consideramos que as experiências que decorreram deste estágio foram fundamentais e permitiram o desenvolvimento das competências inerentes ao Enfermeiro Especialista.

This internship report appears within the scope of the Master's degree in Medical-Surgical Nursing and aims to highlight the experiences and activities developed in order to acquire and develop specialized skills. The structure of the report was guided by the domains of competences defined for the Specialist Nurse by the Order of Nurses, framed in the academic domains recommended by the Educational Institution. The profile of knowledge and skills of the Specialist Nurse in terms of people in critical situations must respond competently to the fragile and complex clinical situation, with their role supported by a framework of differentiated skills framed in respect for the Human Being and their inalienable rights . Focused on the growth and development of specific skills in the area of people in critical situations, as well as the contribution of the Specialized Nurse's differentiated vision to improving the quality of care, we seek to respond to problems encountered in clinical practice. The activities developed highlight the creation of a flowchart to support the triage nurse in the internal referral of patients and a therapeutic protocol for working with adults with fever in the manchester triage. We also highlight the resilient investment in the development and implementation of a complex protocol, within the scope of providing care in an emergency context, to patients in an agitated/aggressive state that aims to mitigate a recurring problem. In the academic domain of research, we developed a qualitative study using the Focus Group technique, with the objective of building a standardized, simplified documentation model that facilitates the nursing record that documents the nurse's role in evaluating and intervening with the patient, during the inter-hospital transport. The conclusions of this research study validated a recording model based on a mnemonic, standardizing and facilitating nursing records during the inter-hospital transport of critically ill patients. We consider that the experiences that took place during this internship were fundamental and allowed the development of skills inherent to Specialist Nurses.

Identification of Predictors for Clinical Deterioration in Patients With COVID-19 via Electronic Nursing Records: Retrospective Observational Study.

BACKGROUND: Few studies have used standardized nursing records with Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) to identify predictors of clinical deterioration. OBJECTIVE: This study aims to standardize the nursing documentation records of patients with COVID-19 using SNOMED CT and identify predictive factors of clinical deterioration in patients with COVID-19 via standardized nursing records. METHODS: In this study, 57,558 nursing statements from 226 patients with COVID-19 were analyzed. Among these, 45,852 statements were from 207 patients in the stable (control) group and 11,706 from 19 patients in the exacerbated (case) group who were transferred to the intensive care unit within 7 days. The data were collected between December 2019 and June 2022. These nursing statements were standardized using the SNOMED CT International Edition released on November 30, 2022. The 260 unique nursing statements that accounted for the top 90% of 57,558 statements were selected as the mapping source and mapped into SNOMED CT concepts based on their meaning by 2 experts with more than 5 years of SNOMED CT mapping experience. To identify the main features of nursing statements associated with the exacerbation of patient condition, random forest algorithms were used, and optimal hyperparameters were selected for nursing problems or outcomes and nursing procedure-related statements. Additionally, logistic regression analysis was conducted to identify features that determine clinical deterioration in patients with COVID-19. RESULTS: All nursing statements were semantically mapped to SNOMED CT concepts for "clinical finding," "situation with explicit context," and "procedure" hierarchies. The interrater reliability of the mapping results was 87.7%. The most important features calculated by random forest were "oxygen saturation below reference range," "dyspnea," "tachypnea," and "cough" in "clinical finding," and "oxygen therapy," "pulse oximetry monitoring," "temperature taking," "notification of physician," and "education about isolation for infection control" in "procedure." Among these, "dyspnea" and "inadequate food diet" in "clinical finding" increased clinical deterioration risk (dyspnea: odds ratio [OR] 5.99, 95% CI 2.25-20.29; inadequate food diet: OR 10.0, 95% CI 2.71-40.84), and "oxygen therapy" and "notification of physician" in "procedure" also increased the risk of clinical deterioration in patients with COVID-19 (oxygen therapy: OR 1.89, 95% CI 1.25-3.05; notification of physician: OR 1.72, 95% CI 1.02-2.97). CONCLUSIONS: The study used SNOMED CT to express and standardize nursing statements. Further, it revealed the importance of standardized nursing records as predictive variables for clinical deterioration in patients.

Prevalence and clustering of NANDA-I nursing diagnoses in the pre-hospital emergency care setting: A retrospective records review study.

AIM: To determine the prevalence and clustering of NANDA-International nursing diagnoses in patients assisted by pre-hospital emergency teams. DESIGN: Retrospective descriptive study of electronic record review. METHODS: Episodes recorded during 2019, including at least a nursing diagnosis, were recovered from the electronic health records of a Spanish public emergency agency (N = 28,847). Descriptive statistics were used to characterize the sample and determine prevalence. A two-step cluster analysis was used to group nursing diagnoses. A comparison between clusters in sociodemographic and medical problems was performed. Data were accessed in November 2020. RESULTS: Risk for falls (00155) (27.3%), Anxiety (00146) (23.2%), Acute pain (00132), Fear (00148) and Ineffective breathing pattern (00032) represented 96.1% of all recorded diagnoses. A six-cluster solution (n = 26.788) was found. Five clusters had a single high-prevalence diagnosis predominance: Risk for falls (00155) in cluster 1, Anxiety (00146) in cluster 2, Fear (00148) in cluster 3, Acute pain (00132) in cluster 4 and Ineffective breathing pattern (00032) in cluster 6. Cluster 5 had several high prevalence diagnoses which co-occurred: Risk for unstable blood glucose level (00179), Ineffective coping (00069), Ineffective health management (00078), Impaired comfort (00214) and Impaired verbal communication (00051). CONCLUSION: Five nursing diagnoses accounted for almost the entire prevalence. The identified clusters showed that pre-hospital patients present six patterns of nursing diagnoses. Five clusters were predominated by a predominant nursing diagnosis related to patient safety, coping, comfort, and activity/rest, respectively. The sixth cluster grouped several nursing diagnoses applicable to exacerbations of chronic diseases. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Knowing the prevalence and clustering of nursing diagnoses allows a better understanding of the human responses of patients attended by pre-hospital emergency teams and increases the evidence of individualized/standardized care plans in the pre-hospital clinical setting. IMPACT: What problem did the study address? There are different models of pre-hospital emergency care services. The use of standardized nursing languages in the pre-hospital setting is not homogeneous. Studies on NANDA-I nursing diagnoses in the pre-hospital context are scarce, and those available are conducted on small samples. What were the main findings? This paper reports the study with the largest sample among the few published on NANDA-I nursing diagnoses in the pre-hospital care setting. Five nursing diagnoses represented 96.1% of all recorded. These diagnoses were related to patients' safety/protection and coping/stress tolerance. Patients attended by pre-hospital care teams are grouped into six clusters based on the nursing diagnoses, and this classification is independent of the medical conditions the patient suffers. Where and on whom will the research have an impact? Knowing the prevalence of nursing diagnoses allows a better understanding of the human responses of patients treated in the pre-hospital setting, increasing the evidence of individualized and standardized care plans for pre-hospital care. REPORTING METHOD: STROBE checklist has been used as a reporting method. NO PATIENT OR PUBLIC CONTRIBUTION: Only patients' records were reviewed without further involvement.

Nurses' Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study.

Background: Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated. Objective: To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia. Methods: An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses' documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study. Results: In this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%-35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36-7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85-6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14-3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11-7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13-6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69-7.52]) were significantly associated with proper nursing care documentation practices. Conclusion: Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses' knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.

Evaluation of a Machine Learning-Based Decision Support Intervention for Inpatient Falls.

Inpatient falls are frequent adverse events, with various injuries occurring in one-third of falls. International practice guidelines recommend multifaceted risk assessment and risk-targeted interventions through multifactorial activities. However, the effectiveness is mixed for such recommendations implemented using traditional approaches. This study proposed a well-designed systemic and clinical decision support approach using machine learning techniques to leverage the implementation of preventive activities of nursing processes leading to outcome changes.

Development of a Cloud-Based Electronic Nursing Record System (ENR) for Nursing Student Practice.

The purpose of this study is to develop cloud-based electronic nursing records (ENR) that can be used as Academic-EMR to help students adapt to the clinical field and improve the clarity of nursing records and nursing information capabilities. This research and development are expected to increase the efficiency of nursing work in clinical sites by improving students' access to ENR through the development of various virtual patient contents.

Association between health literacy and nursing care in hospital: A retrospective study.

AIMS: To describe the health literacy (HL) levels of hospitalised patients and their relationship with nursing diagnoses (NDs), nursing interventions and nursing measures for clinical risks. DESIGN: Retrospective study. METHODS: The study was conducted from December 2020 to December 2021 in an Italian university hospital. From 146 wards, 1067 electronic nursing records were randomly selected. The Single-Item Literacy Screener was used to measure HL. Measures for clinical risks were systematically assessed by nurses using Conley Index score, the Blaylock Risk Assessment Screening Score, Braden score, and the Barthel Index. A univariable linear regression model was used to assess the associations of HL with NDs. RESULTS: Patients with low HL reported a higher number of NDs, interventions and higher clinical risks. HL can be considered a predictor of complexity of care. CONCLUSIONS: The inclusion of standardised terms in nursing records can describe the complexity of care and facilitate the predictive ability on hospital outcomes. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: HL evaluation during the first 24 h. From hospital admission could help to intercept patients at risk of higher complexity of care. These results can guide the development of interventions to minimise needs after discharge. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution was required to design or undertake this research. Patients contributed only to the data collection.

Teor da informação partilhada: Do discurso à documentação na tomada de decisão clínica em enfermagem / Content of shared information: From discourse to documentation in clinical decision-making in nursing / Contenido de la información compartida: Del discurso a la documentación en la toma de decisiones clínicas en enfermería

Resumo Enquadramento: A qualidade dos cuidados depende da informação partilhada oralmente nas transições de cuidados e documentada no processo clínico. Objetivo: Analisar a informação partilhada (oral e escrita) e a sua implicação no âmbito da tomada de decisão clínica em enfermagem e da continuidade de cuidados no serviço de urgência pediátrica, e identificar o paradigma emergente da conceção de cuidados. Metodologia: Abordagem qualitativa, através do estudo de caso, baseado em Yin recorrendo a três métodos: transcrição da passagem de turno, processo documentado e processo realizado pelo perito. Resultados: Maior valorização de dados respeitantes a processos corporais não intencionais, sobretudo na transmissão oral. A informação documentada evidencia maior detalhe no âmbito dos processos adaptativos, contudo incipiente para uma conceção estruturada e intencional da assistência de enfermagem. Conclusão: Sobressai que a informação partilhada oral e escrita, esta focalizada maioritariamente na doença e não tanto na pessoa como um todo. A informação autónoma de enfermagem parece omissa relativamente à dimensão da pessoa, nas respostas humanas às transições e aos processos de vida.

Abstract Background: Quality of care depends on the information shared orally during shift handovers and documented in the clinical records. Objective: To analyze the verbal and written information shared in shift handovers and its impact on clinical decision-making in nursing and the continuity of care in a pediatric emergency ward, as well as identify the emerging paradigm for care. Methodology: Qualitative approach, based on Yin's case study process, using three methods: transcription of the shift handover, documented process, and process carried out by the expert. Results: The results show increased sharing of information about unintentional body processes, especially in oral transmission. Although documented data includes more detailed information about adaptive processes, it is incipient for a structured and intentional conception of nursing care. Conclusion: The verbal and written information shared in shift handovers mainly focuses on the disease rather than the individual as a whole. Autonomous nursing information does not address the dimension of the person, the human responses to transitions, and the life processes.

Resumen Marco contextual: La calidad de los cuidados depende de la información compartida oralmente en las transiciones de cuidados y documentada en la historia clínica. Objetivo: Analizar la información compartida (oral y escrita) y su implicación en la toma de decisiones clínicas en enfermería y en la continuidad de los cuidados en urgencias pediátricas, e identificar el paradigma emergente del diseño de cuidados. Metodología: Enfoque cualitativo, a través del estudio de casos, basado en Yin, en el que se utilizan tres métodos: transcripción del cambio de turno, proceso documentado y proceso llevado a cabo por el experto. Resultados: Mayor valoración de los datos sobre procesos corporales involuntarios, especialmente en la transmisión oral. La información documentada muestra más detalle sobre los procesos adaptativos, pero aún es incipiente para una concepción estructurada e intencional de los cuidados de enfermería. Conclusión: Cabe señalar que la información oral y escrita compartida se centra, sobre todo, en la enfermedad y no en la persona en su conjunto. Parece que falta información autónoma de enfermería en relación con la dimensión de la persona, las respuestas humanas a las transiciones y los procesos vitales.

Avaliação da qualidade dos registros do processo de enfermagem por meio de auditoria retrospectiva / Quality assessment of nursing process records through retrospective audit / Evaluación de la calidad de los registros del proceso de enfermería a través de auditoría retrospectiva

Objetivo: analisar a qualidade dos registros do processo de enfermagem e compará-la segundo as unidades de internação. Método: estudo transversal, retrospectivo que analisou 258 prontuários, entre os meses de março e julho de 2022, de pacientes internados no ano de 2019, em um hospital de grande porte da região Centro-Oeste. Para mensurar a qualidade dos registros, utilizou-se o instrumento Quality of Diagnoses, Interventions and Outcomes, validado para o Brasil. Pesquisa aprovada pelo Comitê de Ética. Resultados: considerando as dimensões dos diagnósticos de enfermagem como processo e como produto, os escores médios gerais de 4,5(±2,6) e 7,1(±4,1), respectivamente. Quanto às dimensões intervenções e resultados de enfermagem, médias de 3,0(±2,1) e 4,7(±4,8). Observaram-se variações das médias de escores entre as unidades analisadas, com diferença significativa (p<0,001). Conclusão: os resultados demonstraram baixos escores de qualidade dos registros do processo de enfermagem, e a média de escores divergiu entre as unidades de internação analisadas(AU)

Objective: To analyze the quality of nursing process records and compare them according to hospitalization units. Method: a cross-sectional, retrospective study that analyzed 258 medical records, between the months of March and July 2022, of patients admitted in 2019, in a large hospital in the Midwest region. The Quality of Diagnoses, Interventions and Outcomes instrument, validated for Brazil, was used to measure the quality of the records. The study was approved by the Ethics Committee. Results: considering the dimensions of nursing diagnoses as a process and as a product, the overall mean scores were 4.5(±2.6) and 7.1(±4.1), respectively. As for the dimensions of nursing interventions and outcomes, the mean scores were 3.0(±2.1) and 4.7(±4.8). There were variations in the mean scores between the units analyzed, with a significant difference (p<0.001). Conclusion: The results showed low quality scores for nursing process records, and the mean scores differed between the inpatient units analyzed(AU)

Objetivo: analizar la calidad de los registros del proceso de enfermería y compararla según las unidades de hospitalización. Método: estudio transversal, retrospectivo, que analizó 258 historias clínicas, entre marzo y julio de 2022, de pacientes internados en 2019 en un gran hospital de la región Centro-Oeste. Para medir la calidad de los registros, se utilizó el instrumento Quality of Diagnoses, Interventions and Outcomes (Calidad de Diagnósticos, Intervenciones y Resultados), validado para Brasil. El Comité de Ética aprobó la investigación. Resultados: considerando las dimensiones de los diagnósticos de enfermería como proceso y como producto, las puntuaciones medias globales fueron 4,5(±2,6) y 7,1(±4,1), respectivamente. En cuanto a las dimensiones de las intervenciones de enfermería y los resultados, los promedios fueron de 3,0(±2,1) y 4,7(±4,8). Hubo variaciones en los promedios de las puntuaciones entre las unidades analizadas, con una diferencia significativa (p<0,001). Conclusión: Los resultados mostraron bajas puntuaciones de calidad en los registros de procesos de enfermería, y los promedios de las puntuaciones difirieron entre las unidades de hospitalización analizadas(AU)

The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study.

PURPOSE: To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument. METHODS: A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument. FINDINGS: Low quality levels of nursing process documentation were found. The Q-DIO subscale "Nursing diagnoses as process" (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. "Nursing diagnoses as product" showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29). Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for "Nursing diagnoses as process." CONCLUSIONS: The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes. IMPLICATIONS FOR NURSING PRACTICE: This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.

Improving Nursing Assessment in Adult Hospitalization Units: A Secondary Analysis.

The main objective of this study was to analyze the impact of a multifaceted strategy to improve the assessment of functional capacity, risk of pressure injuries, and risk of falls at the time of admission of patients in adult hospitalization units. This was a secondary analysis of the VALENF project databases during two periods (October-December 2020, before the strategy, and October-December 2021, after the strategy). The quantity and quality of nursing assessments performed on patients admitted to adult hospitalization units were evaluated using the Barthel index, Braden index, and Downton scale. The number of assessments completed before the implementation of the new strategy was n = 686 (28.01%), versus n = 1445 (58.73%) in 2021 (p < 0.001). The strategy improved the completion of the evaluations of the three instruments from 63.4% (n = 435) to 71.8% (n = 1038) (p < 0.001). There were significant differences depending on the hospitalization unit and the assessment instrument (p < 0.05). The strategy employed was, therefore, successful. The nursing assessments show a substantial improvement in both quantity and quality, representing a noticeable improvement in nursing practice. This study was not registered.

Impact of an Electronic Medical Record-Connected Questionnaire on Efficient Nursing Documentation: Usability and Efficacy Study.

BACKGROUND: Documentation tasks comprise a large percentage of nurses' workloads. Nursing records were partially based on a report from the patient. However, it is not a verbatim transcription of the patient's complaints but a type of medical record. Therefore, to reduce the time spent on nursing documentation, it is necessary to assist in the appropriate conversion or citation of patient reports to professional records. However, few studies have been conducted on systems for capturing patient reports in electronic medical records. In addition, there have been no reports on whether such a system reduces the time spent on nursing documentation. OBJECTIVE: This study aims to develop a patient self-reporting system that appropriately converts data to nursing records and evaluate its effect on reducing the documenting burden for nurses. METHODS: An electronic medical record-connected questionnaire and a preadmission nursing questionnaire were administered. The questionnaire responses entered by the patients were quoted in the patient profile for inpatient assessment in the nursing system. To clarify its efficacy, this study examined whether the use of the electronic questionnaire system saved the nurses' time entering the patient profile admitted between August and December 2022. It also surveyed the usability of the electronic questionnaire between April and December 2022. RESULTS: A total of 3111 (78%) patients reported that they answered the electronic medical questionnaire by themselves. Of them, 2715 (88%) felt it was easy to use and 2604 (85%) were willing to use it again. The electronic questionnaire was used in 1326 of 2425 admission cases (use group). The input time for the patient profile was significantly shorter in the use group than in the no-use group (P<.001). Stratified analyses showed that in the internal medicine wards and in patients with dependent activities of daily living, nurses took 13%-18% (1.3 to 2 minutes) less time to enter patient profiles within the use group (both P<.001), even though there was no difference in the amount of information. By contrast, in the surgical wards and in the patients with independent activities of daily living, there was no difference in the time to entry (P=.50 and P=.20, respectively), but there was a greater amount of information in the use group. CONCLUSIONS: The study developed and implemented a system in which self-reported patient data were captured in the hospital information network and quoted in the nursing system. This system contributes to improving the efficiency of nurses' task recordings.

Avaliação dos registros de enfermagem sobre oxigenação por membrana extracorpórea em equipe multidisciplinar treinada / Evaluation of nursing records on extracorporal membrane oxygenation after multidisciplinary training / Evaluación de registros de enfermería sobre oxigenación por membrana extracorpórea después de entrenamiento multidisciplinar

Objetivos: comparar o conteúdo dos registros de enfermagem referente à oxigenação por membrana extracorpórea (ECMO) entre os períodos de pré e pós-treinamento da equipe multidisciplinar. Método: estudo retrospectivo realizado em uma unidade de terapia intensiva adulto, com pacientes em uso de ECMO entre 2012 e 2019. Foram analisadas as informações das anotações, evoluções e prescrições de enfermagem sobre a ECMO. Resultados: foram incluídos 194 registros de enfermagem, que evidenciaram melhora na qualidade da evolução de enfermagem referente às informações da ECMO no período pós-treinamento. Dentre as informações, destaca-se a qualidade do registro sobre o circuito e a membrana. Conclusão: o treinamento multidisciplinar em ECMO foi fundamental para a melhoria das informações nas evoluções de enfermagem. Contudo, a continuidade de treinamentos se faz essencial para manutenção adequada dos registros de enfermagem que envolvem este suporte

Objectives: to compare nursing records regarding extracorporeal membrane oxygenation (ECMO) between pre- and post-multidisciplinary training. Method:A retrospective study was conducted in an Intensive Care Unit (ICU) with patients using ECMO, between 2012 and 2019. Notes, evolutions and nursing prescriptions on ECMO were analyzed. Results: the 194 nursing records analyzed revealed an improvement in the quality of nursing records regarding ECMO information post-training. Among the information, the quality of circuit and membrane records stands out. Conclusion: multidisciplinary training in ECMO was fundamental for improving information in nursing evolutions. However, continued training is essential for the proper maintenance of nursing records regarding this suppor

Objetivos: comparar el contenido de los registros de enfermería con respecto a la oxigenación por membrana extracorpórea (ECMO) entre los períodos pre y pos-entrenamiento del equipo multidisciplinario. Método: estudio retrospectivo, realizado en una unidad de cuidados intensivos (UCI), con pacientes en uso de ECMO entre 2012 y 2019. Se analizó información de notas, evoluciones y prescripciones de enfermería sobre ECMO. Resultados: se incluyeron 194 registros de enfermería, en los cuales se observó una mejora de la calidad en las evoluciones de enfermería respecto a la información de la ECMO en el período posterior al entrenamiento. Entre las informaciones destaca la calidad del registro en circuito y la membrana tras el entrenamiento. Conclusión: el entrenamiento multidisciplinar en ECMO fue fundamental para mejorar la información en los registros de enfermería. Sin embargo, la continuidad del entrenamiento es clave para el correcto mantenimiento de los registros de enfermería en relación con este apoyo

Evaluation of the Evolution of Digital Nursing Interventions in an Emergency Unit: An Observational Study.

This study aimed to examine the influence of new ICTs on the recording of nursing interventions in the Emergency Unit of the High Resolution Hospital (HRH) of Loja (Granada), Spain. A descriptive observational study was conducted to analyze the evolution of the Nursing Interventions (NIC) records in the Emergency Unit of the Loja HRH (Granada) from 2017 to 2021. Results showed that 11,076 NIC registrations were exploited, which increased by 51.2% from 2017 to 2021. The linear correlation between the NIC and the years was analyzed with Spearman's coefficient, obtaining a low level of correlation (p = 0.166), but one that is statistically significant (p < 0.001). The introduction of tablet devices in the emergency room of the Loja HRH (Granada) led to a significant increase in the percentage of NIC recorded and collated during the study period without increasing the number of emergencies attended. However, usability barriers of ICTs were detected, highlighting the need to guide and train health professionals in their use and in the culture of patient safety.

'It's all about ticks': A secondary qualitative analysis of nurse perspectives about documentation audit.

AIM: To understand how nurses talk about documentation audit in relation to their professional role. BACKGROUND: Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process. DESIGN: Secondary qualitative thematic analysis. METHODS: Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study. RESULTS: Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences. CONCLUSION: Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows. IMPACT: Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation. NO PATIENT OR PUBLIC CONTRIBUTION: Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.

Avaliação dos registros de enfermeiros em unidade de terapia intensiva baseado na resolução Cofen nº 429/2012 / Evaluation of the records of nurses in the intensive care unit based on the Cofen resolution nº429/2012 / Evaluación de registros de enfermeras en la unidad de cuidados intensivos basado en la resolución Cofen nº 429/2012

Objetivo: Avaliar a qualidade dos registros de enfermeiros em Unidade de Terapia Intensiva baseado na Resolução No. 429/2012 do Conselho Federal de Enfermagem. Métodos: Estudo documental e avaliativo realizado em Unidade de Terapia Intensiva de um hospital universitário no Rio de Janeiro em janeiro de 2017. A amostra foi composta por 312 registros. Para a coleta de dados foi construído um instrumento com base nas determinações da Resolução No. 429/2012. Resultados: Constatou-se que 46,8% dos registros da coleta de dados, estavam incompletos e voltavam-se, predominantemente, para a dimensão biológica do corpo e para a utilização de dispositivos sem, contudo, fornecer informações consistentes e que sustentassem as demais etapas do processo de enfermagem. O diagnóstico de enfermagem com base nas taxonomias existentes, não foi encontrado em nenhum registro. Quanto a anotação das ações realizadas e da avaliação, 68,3% e 85,9%, respectivamente, estavam incompletas. Conclusão: Na avaliação dos registros dos enfermeiros, mais de 90,0% mostraram-se incompletos e não atenderam aos padrões determinados pela Resolução No. 429/2012. Portanto, os registros avaliados não atendem aos preceitos éticos e legais da profissão. (AU)

Objective: To assess the quality of records of nurses in the Intensive Care Unit based on Resolution No. 429/2012. Federal Council of Nursing. Methods: Documentary and evaluative study carried out in the Intensive Care Unit of a university hospital in Rio de Janeiro in January 2017. The sample consisted of 312 records. For data collection, an instrument was built based on the determinations of the Resolution No. 429/2012. Results: It was found that 46.8% of the data collection records were incomplete and predominantly focused on the biological dimension of the body and the use of devices without, however, providing consistent information that would support the others stages of the nursing process. The nursing diagnosis based on existing taxonomies was not found in any record. As for the annotation of the actions taken and the evaluation, 68.3% and 85.9%, respectively, were incomplete. Conclusion: In the evaluation of nurses' records, more than 90,0% were incomplete and did not meet the standards determined by Resolution No. 429/2012. Therefore, the evaluated records do not meet the ethical and legal precepts of the profession. (AU)

Objetivo: Evaluar la calidad de los registros de enfermeras en la Unidad de Cuidados Intensivos basado en la Resolución No. 429/2012 Consejo Federal de Enfermeria. Métodos: Estudio documental y evaluativo realizado en la Unidad de Cuidados Intensivos de un hospital universitario en Rio de Janeiro en Enero de 2017. La muestra estuvo conformada por 312 registros. Para la recolección de datos se construyó un instrumento en base a las determinaciones de la Resolución No. 429/2012. Resultados: Se encontró que el 46.8% de los registros de recolección de datos estaban incompletos y predominantemente enfocados en la dimensión biológica del cuerpo y el uso de dispositivos sin, sin embargo, brindar información consistente que sustente las otras etapas del proceso de enfermería. El diagnóstico de enfermería basado en taxonomías existentes no se encontró en ningún registro. En cuanto a la anotación de las acciones realizadas y la evaluación, 68,3% y 85,9%, respectivamente, fueron incompletas. Conclusión: En la evaluación de los registros de enfermeras, más del 90,0% estaban incompletos y no cumplían con los estándares determinados por la Resolución No. 429/2012. Por tanto, los expedientes evaluados no cumplen con los preceptos éticos y legales de la profesión. (AU)

Registros de enfermagem referentes à inserção de cateteres nasogástricos e nasoenterais: não conformidades e sub-registro / Nursing records regarding the insertion of nasogastric and nasoenteral catheters: nonconformities and sub-recording / Registros de enfermería respecto a la inserción de sondas nasogástricas y nasoenterales: no conformidades y subregistros

Objetivo: O registro dos dados referentes a Terapia Nutricional Enteral (TNE) é importante para assegurar o procedimento e comunicação sistemática da assistência. Com o estudo, objetivou-se analisar os registros de enfermagem referentes à inserção de cateteres nasogástricos (CNG) e nasoenterais (CNE) considerando o sub-registro e não conformidades encontradas em prontuários e durante observação dos pacientes. Métodos: estudo observacional, transversal com abordagem quantitativa, mediante a aplicação de instrumento para coleta de dados de pacientes internados em um Hospital Universitário no Pará entre agosto de 2019 a julho de 2020. Resultados: Foram identificadas 191 inserções de cateteres por enfermeiros, sendo 43 (22,52%) reinserções sub-registradas e 148 (77,48%) apresentaram não conformidades. Discussão: O sub-registro e as não conformidades interferem na qualidade da assistência de enfermagem, fragilizam as ações de segurança do paciente, além de apresentarem repercussões legais. Conclusão: Os dados apresentados neste artigo foram primordiais para a detecção de lacunas na assistência de enfermagem. (AU)

Objective: The recording of data referring to Enteral Nutrition Therapy (ENT) is important to ensure the procedure and systematic communication of care. The objective was to analyze the nursing records regarding the insertion of nasogastric (CNG) and nasoenteral (CNE) catheters, considering the under-recording and non-conformities found in medical records and during patient observation. Methods: observational, cross-sectional study with a quantitative approach, through the application of an instrument to collect data from patients admitted to a University Hospital in Pará between August 2019 and July 2020. Results: 191 insertions of catheters by nurses were identified, of which 43 (22.52%) underreported reinsertion and 148 (77.48%) presented non-conformities. Discussion: Under-registration and non-compliance interfere with the quality of nursing care, weaken patient safety actions, in addition to having legal repercussions. Conclusion: The data presented in this article were essential for the detection of gaps in nursing care. (AU)

Objetivo: El registro de los datos referentes a la Terapia de Nutrición Enteral (ENT) es importante para garantizar el procedimiento y la comunicación sistemática de los cuidados. El objetivo fue analizar los registros de enfermería con respecto a la inserción de catéteres nasogástricos (GNC) y nasoenterales (CNE), considerando el subregistro y las no conformidades encontradas en los registros médicos y durante la observación de los pacientes. Métodos: estudio observacional, transversal con abordaje cuantitativo, mediante la aplicación de un instrumento para recolectar datos de pacientes internados en un Hospital Universitario de Pará entre agosto de 2019 y julio de 2020. Resultados: fueron identificadas 191 inserciones de catéteres por enfermeros, de de los cuales 43 (22,52%) subreportaron reinserción y 148 (77,48%) presentaron no conformidades. Discusión: El subregistro y el incumplimiento interfieren en la calidad de la atención de enfermería, debilitan las acciones de seguridad del paciente, además de tener repercusiones legales. Conclusión: Los datos presentados en este artículo fueron esenciales para la detección de lagunas en el cuidado de enfermería. (AU)