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1.
Rev. enferm. UFSM ; 12: e2, 2022. tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1344115

RESUMO

Objetivo: analisar a aplicabilidade do Processo de Enfermagem em interface com as melhores práticas. Método: estudo transversal, realizado com 146 enfermeiros(as), mediante questionário estruturado tipo survey, aplicado entre maio e setembro de 2019, analisado por estatística descritiva e inferencial. Resultados: dos 146 enfermeiros(as), 115 (78,8%) realizavam o Processo de Enfermagem, sendo que 73 (50%) aplicavam as cinco etapas do Processo de Enfermagem. Destes 115, prevaleceram as etapas de coleta de dados 110 (95,7%) e implementação do cuidado 104 (90,4%). Houve associação significativa entre a aplicação das etapas do Processo de Enfermagem com o uso de sistemas de informação e escalas de avaliação. Algumas etapas do Processo foram associadas ao uso de Sistemas de Linguagem Padronizada e teorias de enfermagem. Conclusão: o Processo de Enfermagem configura-se como estratégia para consolidar as melhores práticas, fundamentando as ações em evidências científicas e nas necessidades do indivíduo mediante expertise clínica e qualificação dos registros.


Objective: to analyze the applicability of the Nursing Process in interface with best practices. Method: cross-sectional study, conducted with 146 nurses, using a structured survey questionnaire, applied between May and September 2019, analyzed by descriptive and inferential statistics. Results: of the 146 nurses, 115 (78.8%) performed the Nursing Process, and 73 (50%) applied the five steps of the Nursing Process. Of these 115 prevailed the steps of data collection 110 (95.7%) and implementation of care 104 (90.4%). There was a significant association between the application of the steps of the Nursing Process using information systems and evaluation scales. Some steps of the Process were associated with the use of Standardized Language Systems and nursing theories. Conclusion: the Nursing Process is configured as a strategy to consolidate the best practices, basing the actions on scientific evidence and on the needs of the individual through clinical expertise and qualification of the records.


Objetivo: analizar la aplicabilidad del Proceso de Enfermería en interfaz con las mejores prácticas. Método: estudio transversal, realizado con 146 enfermeros, utilizando un cuestionario de encuesta estructurada, aplicado entre mayo y septiembre de 2019, analizado por estadística descriptiva e inferencial. Resultados: de los 146 enfermeros, 115 (78,8%) realizaron el Proceso de Enfermería, y 73 (50%) aplicaron las cinco etapas del Proceso de Enfermería. De esos 115, prevalecieron las etapas de recolección de datos 110 (95,7%) y la implementación de la atención 104 (90,4%). Hubo asociación significativa entre la aplicación de las etapas del Proceso de Enfermería con el uso de sistemas de información y escalas de evaluación. Algunas etapas del Proceso fueron asociadas con el uso de sistemas estandarizados del lenguaje y teorías de enfermería. Conclusión: el Proceso de Enfermería se configura como una estrategia para consolidar las mejores prácticas, basando las acciones en la evidencia científica y en las necesidades del individuo a través de la experiencia clínica y la calificación de los registros.


Assuntos
Humanos , Atenção Terciária à Saúde , Registros de Enfermagem , Enfermagem , Padrões de Prática em Enfermagem , Processo de Enfermagem
2.
Artigo em Inglês | MEDLINE | ID: mdl-34769780

RESUMO

The COVID-19 pandemic has led to an increased workload for nurses and organisational and structural changes, which have been necessary to meet the needs of inpatients in isolation. AIM: To describe the impact of the COVID-19 pandemic on levels of adherence to the completion of nursing records that document the risk of developing pressure ulcers, falling, and social vulnerability among hospitalised patients in isolation. METHODS: Observational pre-post comparison study. Comparison between nursing records (the Braden, Downton, and Gijón scales) belonging to 1205 inpatients took place in two phases. Phase 1: 568 patients admitted in February 2020, prior to the COVID-19 pandemic, vs. phase 2: 637 patients hospitalised with COVID-19 in March-April 2020, during the peak of the first wave of the pandemic. This research adheres to the STROBE guidelines for the reporting of observational studies. RESULTS: The degree of completion of the Braden, Downton, and Gijón scales decreased significantly in phase 2 vs. phase 1 (p < 0.001). The mean Downton and Gijón scale scores for patients admitted in phase 1 were higher compared to those of patients admitted in phase 2 (p < 0.001). The mean Braden scale score in phase 2 was higher than in phase 1 (p < 0.05). CONCLUSION: During the COVID-19 pandemic, there was a decrease in the completion of nursing records in the clinical records of patients in isolation. The levels of risk of developing PUs, falling, and social vulnerability of patients admitted to hospital were lower during the first wave of the pandemic.


Assuntos
COVID-19 , Pacientes Internados , Humanos , Registros de Enfermagem , Pandemias , SARS-CoV-2
3.
Enferm. foco (Brasília) ; 12(2): 216-222, set. 2021. tab, ilus
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1291190

RESUMO

Objetivo: Analisar os registros de enfermagem nas consultas em puericultura de crianças de 0 a 18 meses assistidas em Unidade de Saúde da Família. Métodos: Estudo documental, realizado através de pesquisa em prontuários de uma Unidade de Saúde da Família, composta por quatro equipes de saúde da família, no município do Recife, Pernambuco. A amostra foi composta por 108 prontuários de lactentes de zero a 18 meses. Os dados foram analisados por meio de análise descritiva. Resultados: Em relação aos registros de enfermagem, pôde-se observar que em apenas 1,9% dos prontuários constavam todas as medidas antropométricas, e somente 6,5% apresentavam os marcos do desenvolvimento. Nos registros de alimentação, 58,7% dos prontuários registravam a duração do aleitamento materno exclusivo, e quando se fazia uso de leite industrializado, apenas 6,9% apresentavam sua diluição. Quanto à prescrição de suplementação de ferro, houve registro em 4,6% dos prontuários, dos quais nenhum descreveu o esquema de suplementação prescrito. Em relação à imunização, 99,1% apresentavam registro acerca da vacinação. Conclusão: Observou-se uma lacuna nos registros das consultas de enfermagem em puericultura, com ausência de informações no prontuário essenciais para o acompanhamento sistemático da saúde da criança. (AU)


Objective: To analyze nursing records in childcare consultations for children aged 0 to 18 months assisted in a Family Health Unit. Methods: Documentary study, carried out through research in medical records of a Family Health Unit, composed of four family health teams, in the city of Recife, Pernambuco. The sample consisted of 108 medical records of infants aged zero to 18 months. The data were analyzed through descriptive analysis. Results: Regarding the nursing records, it was observed that only 1.9% of the medical records contained all anthropometric measurements, and only 6.5% had the developmental milestones. In the food records, 58.7% of the medical records recorded the duration of exclusive breastfeeding, and when industrialized milk was used, only 6.9% presented its dilution. Regarding the prescription of iron supplementation, 4.6% of the medical records were recorded, of which none described the prescribed supplementation scheme. Regarding immunization, 99.1% had a record about vaccination. Conclusion: There was a gap in the records of nursing consultations in childcare, with the absence of information in the medical records essential for the systematic monitoring of child health. (AU)


Objetivo: Analizar los registros de enfermería en consultas de cuidado infantil para niños de 0 a 18 meses atendidos en una Unidad de Salud Familiar. Métodos: Estudio documental, realizado a través de la investigación en registros médicos de una Unidad de Salud Familiar, compuesta por cuatro equipos de salud familiar, en la ciudad de Recife, Pernambuco. La muestra consistió en 108 registros médicos de bebés de zero a 18 meses. Los datos se analizaron mediante análisis descriptivo. Resultados: Con respecto a los registros de enfermería, se observó que solo el 1.9% de los registros médicos contenía todas las medidas antropométricas, y solo el 6.5% tenía hitos en el desarrollo. En los registros de alimentos, el 58.7% de los registros médicos registraron la duración de la lactancia materna exclusiva, y cuando se usó leche industrializada, solo el 6.9% presentó su dilución. Con respecto a la prescripción de suplementos de hierro, se registró el 4,6% de los registros médicos, de los cuales ninguno describió el esquema de suplementos prescrito. Con respecto a la inmunización, el 99.1% tenía un registro sobre vacunación. Conclusion: Hubo una brecha en los registros de consultas de enfermería en el cuidado de niños, con la ausencia de información en los registros médicos esenciales para el monitoreo sistemático de la salud infantil. (AU)


Assuntos
Registros de Enfermagem , Cuidado da Criança , Enfermagem no Consultório , Saúde do Lactente , Cuidados de Enfermagem
4.
Enferm. foco (Brasília) ; 12(2): 230-236, set. 2021. ilus
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1291238

RESUMO

Objetivo: Elaborar vídeos tutoriais sobre registros de enfermagem, com foco na legislação vigente. Metodologia: Pesquisa aplicada à produção de objetos de aprendizagem, executada dentro dos parâmetros de desenvolvimento tecnológico do Modelo ADDIE (analysis ­ análise, design - desenho, development - desenvolvimento, implementation - implementação e evaluation - avaliação). A edição dos vídeos tutoriais produzidos foi realizada com os recursos do software Vyond. Para viabilizar o acesso do público alvo, os vídeos foram postados no Youtube. Resultados: Uma série, composta por quatro vídeos animados, sobre os aspectos legais dos registros de enfermagem. Os assuntos abordados sobre a temática escolhida são: 1) Generalidades; 2) Documentos gerenciais; 3) Processo de enfermagem e; 4) Anotações de enfermagem. Conclusão: A criação dos vídeos colabora para a qualificação profissional, porém, é apenas uma das diversas ações necessárias para que este objetivo seja alcançado. (AU)


Objective: To prepare tutorial videos on nursing records, focusing on current legislation. Methods: Research applied to the production of learning objects, carried out within the parameters of technological development of the ADDIE Model (analysis, design, development, implementation and evaluation). The editing of the tutorial videos produced was carried out with the resources of the Vyond software. To make the target audience accessible, the videos were posted on Youtube. Results: A series, consisting of four animated videos, on the legal aspects of nursing records. The subjects covered on the chosen theme are: 1) Generalities; 2) Management documents; 3) Nursing process and; 4) Nursing notes. Conclusion: The creation of videos contributes to professional qualification, however, it is only one of the several actions necessary for this objective to be achieved. (AU)


Objetivo: Preparar videos tutoriales sobre registros de enfermería, centrándose en la legislación vigente. Metodos: Investigación aplicada a la producción de objetos de aprendizaje, realizada dentro de los parámetros de desarrollo tecnológico del Modelo ADDIE (análisis análisis, diseño - diseño, desarrollo - desarrollo, implementación - implementación y evaluación - evaluación). La edición de los videos tutoriales producidos se realizó con los recursos del software Vyond. Para que el público objetivo sea accesible, los videos se publicaron en Youtube. Resultados: Una serie, que consta de cuatro videos animados, sobre los aspectos legales de los registros de enfermería. Los temas tratados sobre el tema elegido son: 1) Generalidades; 2) documentos de gestión; 3) proceso de enfermería y; 4) Notas de enfermería. Conclusión: La creación de videos contribuye a la calificación profesional, sin embargo, es solo una de las varias acciones necesarias para lograr este objetivo. (AU)


Assuntos
Registros de Enfermagem , Enfermagem , Legislação de Enfermagem , Processo de Enfermagem
5.
Comput Methods Programs Biomed ; 210: 106364, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34500143

RESUMO

BACKGROUND AND OBJECTIVE: This study describes the integration of a spoken dialogue system and nursing records on an Android smartphone application intending to help nurses reduce documentation time and improve the overall experience of a healthcare setting. The application also incorporates with collecting personal sensor data and activity labels for activity recognition. METHODS: We developed a joint model based on a bidirectional long-short term memory and conditional random fields (Bi-LSTM-CRF) to identify user intention and extract record details from user utterances. Then, we transformed unstructured data into record inputs on the smartphone application. RESULTS: The joint model achieved the highest F1-score at 96.79%. Moreover, we conducted an experiment to demonstrate the proposed model's capability and feasibility in recording in realistic settings. Our preliminary evaluation results indicate that when using the dialogue-based, we could increase the percentage of documentation speed to 58.13% compared to the traditional keyboard-based. CONCLUSIONS: Based on our findings, we highlight critical and promising future research directions regarding the design of the efficient spoken dialogue system and nursing records.


Assuntos
Registros de Enfermagem , Smartphone , Coleta de Dados , Registros Eletrônicos de Saúde , Humanos
6.
Nursing (Säo Paulo) ; 24(279): 6101-6114, ago.-2021.
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1343595

RESUMO

Objetivo: analisar o método de registro da enfermagem realizado no prontuário do paciente admitido na Sala de Recuperação Pós-Anestésica de um Hospital Geral no extremo Norte do Brasil. Método: Estudo descritivo, do tipo documental com abordagem quantitativa. Resultados: Dos 24 prontuários analisados, 91,66% apresentavam ficha de sistematização da assistência preenchida de forma parcial e 8,33% não continham a ficha ou anotação dos parâmetros vitais. Com identificação legal e ética 91,67% dos prontuários e 87,5% utilizavam apenas abreviaturas reconhecidas. 41,67% dos registros estavam ilegíveis e 91,67% apresentavam linhas em branco. Conclusão: O instrumento de registros em prontuário utilizado no centro cirúrgico pelos Enfermeiros se mostrou limitado e incompleto, não atendendo ao guia Cofen para registro pós-operatório ou às recomendações da SOBECC e da Associação Brasileira de Enfermeiros de Centro Cirúrgico/Recuperação Anestésica, evidenciando fragilidade na assistência de enfermagem prestada.(AU)


Objective: to analyze the method of nursing registration performed in the medical record of patients admitted to the Post-Anesthetic Recovery Room of a General Hospital in the far North of Brazil. Method: Descriptive study, documentary type with a quantitative approach. Results: Of the 24 medical records analyzed, 91.66% had a care systematization form partially filled in and 8.33% did not contain the form or note of vital parameters. With legal and ethical identification, 91.67% of the medical records and 87.5% used only recognized abbreviations. 41.67% of the records were illegible and 91.67% had blank lines. Conclusion: The medical record instrument used in the operating room by nurses proved to be limited and incomplete, not complying with the Cofen guide for postoperative registration or with the recommendations of SOBECC and the Brazilian Association of Surgical/Anesthetic Recovery Nurses, showing fragility in the nursing care provided.(AU)


Objetivo: analizar el método de registro de enfermería realizado en la historia clínica de los pacientes ingresados en la Sala de Recuperación Postanestésica de un Hospital General del extremo norte de Brasil. Método: Estudio descriptivo, tipo documental con enfoque cuantitativo. Resultados: De las 24 historias clínicas analizadas, el 91,66% tenía formulario de sistematización de la atención parcialmente cumplimentado y el 8,33% no contenía el formulario o nota de parámetros vitales. Con identificación legal y ética, el 91,67% de las historias clínicas y el 87,5% utilizaron solo abreviaturas reconocidas. El 41,67% de los registros eran ilegibles y el 91,67% tenía líneas en blanco. Conclusión: El instrumento de historia clínica utilizado en el quirófano por enfermeras resultó ser limitado e incompleto, no cumpliendo con la guía Cofen para el registro posoperatorio o con las recomendaciones de la SOBECC y la Asociación Brasileña de Enfermeras de Recuperación Quirúrgica / Anestésica, mostrando fragilidad en atención de enfermería proporcionada.(AU)


Assuntos
Humanos , Período de Recuperação da Anestesia , Registros de Enfermagem , Cuidados de Enfermagem/métodos , Registros Médicos , Controle de Formulários e Registros
7.
Comput Inform Nurs ; 39(10): 584-591, 2021 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-34225309

RESUMO

A German regulation requires nursing managers to document patient-nurse ratios. They have to combine heterogeneous hospital data from different sources. Missing documentation or ratios that are too high lead to sanctions. Automated approaches are needed to accelerate the time-consuming and error-prone documentation process. A documentation and visualization system was implemented. The system allows nursing managers to quickly and automatically create the documentation required by the regulation. Interactive visualization dashboards assist with the analysis of patient and staff numbers. The developed method was effectively used in nursing management tasks. No changes to the information technology infrastructure were needed. The new process is around 35 hours per month faster and less error-prone. The documentation functionality automatically reads the required information and correctly calculates the documentation. The visualization functionality allows nursing managers to assess the current patient-nurse ratios before the documentation is submitted. The method scales to multiple wards and locations. It calculates the sanctions to expect and is easily updatable. The proposed method is expected to decrease nursing administration workloads and facilitate the analysis of nursing management data in a cost-effective way.


Assuntos
Cuidados de Enfermagem , Processo de Enfermagem , Documentação , Humanos , Relações Enfermeiro-Paciente , Registros de Enfermagem , Carga de Trabalho
8.
Rev Esc Enferm USP ; 55: e03711, 2021.
Artigo em Inglês, Português | MEDLINE | ID: mdl-34190880

RESUMO

OBJECTIVE: To implement the nursing process, based on the Neuman Systems Model and the International Classification of Nursing Practice terminology, in the care of an adolescent who underwent corrective surgery for juvenile idiopathic scoliosis. METHOD: This is a qualitative study of the type of single case, with triangulation of data collection techniques (formal clinical interview, notes in a field diary and medical record information), developed with a 17-year-old adolescent and indication for corrective surgery. The empirical materials generated with the interviews carried out at admission and at discharge, observation and medical record information were treated with categorical content analysis. RESULTS: The categories of personal condition, anxiety, selfconcept, meaningful people, facilitating health resources, school, free time and leisure were recurrent. Diagnoses were defined with a focus on Anxiety, Knowledge on pain management (control) and Willingness (or readiness) to learn, associating them with the respective nursing interventions. CONCLUSION: The Model contributed to assess and recognize surgery stressors for the adolescent and to theoretically base the nursing process. The classification allowed systematizing nursing care records, elements of clinical practice, unifying vocabulary and codes.


Assuntos
Processo de Enfermagem , Escoliose , Terminologia Padronizada em Enfermagem , Adolescente , Humanos , Registros de Enfermagem , Enfermagem Perioperatória , Escoliose/cirurgia
9.
Semina cienc. biol. saude ; 42(2): 187-200, jun./dez. 2021. Tab
Artigo em Português | LILACS | ID: biblio-1293122

RESUMO

Introdução: os sistemas de classificação com linguagens padronizadas se estabelecem em um conjunto de conhecimentos estruturados, conceitos fundados de forma lógica e coerente, com base em suas similaridades. Nesse sentido, identificar um perfil junto a populações pode cooperar para uma melhor definição e compreensão situacional para aquela unidade e/ou pacientes. Objetivos: realizar mapeamento cruzado entre os diagnósticos de enfermagem da NANDA-I com os registros manuais de enfermagem em sala de recuperação pós-anestésica; e propor intervenções e resultados, segundo linguagens padronizadas. Método: estudo exploratório, retrospectivo com análise estatística descritiva de registros de enfermagem de 187 pacientes que estiveram hospitalizados no período de junho a julho de 2018, em sala de recuperação pós-anestésica de um hospital oncológico. O mapeamento cruzado foi realizado em três etapas: identificação dos indicadores dos diagnósticos; proposição de intervenções e atividades; e indicadores de resultados. Os dados foram analisados e descritos em frequências absoluta e relativa. Resultados: dos 13 domínios da NANDA-I, cinco foram representados; identificaram-se cinco diagnósticos de risco e 11 com foco no problema; observou-se 100% de frequência para os diagnósticos de: Risco de aspiração; Risco de infecção; Risco de queda; Capacidade de transferência prejudicada; Mobilidade no leito prejudicada; Integridade da pele/tissular prejudicada e Conforto prejudicado. Conclusões: para os 16 diagnósticos de enfermagem mapeados, foram selecionadas 22 intervenções e 58 atividades; 23 resultados e 48 indicadores de resultados.


Introduction: the classification systems with standardized languages are established in a set of structured knowledge, concepts founded in a logical and coherent way, based on their similarities. In this sense, identifying a profile with the populations can cooperate for a better definition and situational understanding for that unit and/or patients. Objectives: to perform cross-mapping between the nursing diagnoses of NANDA-I with the manual nursing records in the post-anesthetic recovery room; and, to propose interventions and outcomes, according to standardized language. Method: exploratory, descriptive and retrospective analysis of the nursing records of 187 patients hospitalized from June to July 2018, in the post-anesthetic recovery room of an oncology hospital. Cross-mapping was carried out in three stages: identification of diagnostic indicators; proposition of interventions and activities; and outcomes indicators. The data were analyzed and described in absolute and relative frequencies. Results: of the 13 NANDA-I domains, five were highlighted; were identified five risk diagnoses and 11 focused on the problem; 100% frequency was observed for the diagnoses of: Aspiration, infection and falling risk; Impaired transfer capacity; Impaired bed mobility; Impaired skin/tissue integrity and impaired comfort. Conclusions: from the 16 nursing diagnoses mapped, were selected 22 interventions and 58 activities; 23 results and 48 outcomes indicators.


Assuntos
Humanos , Registros de Enfermagem , Enfermagem em Pós-Anestésico , Terminologia Padronizada em Enfermagem , Anestesia
10.
Pflege ; 34(4): 191-202, 2021 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-33971724

RESUMO

Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings Abstract. Background: In Germany, there was previously no instrument for the systematic recording of preferences for the everyday living of older and people in need of care. Subsequently, in a pilot study, an instrument was translated in a culturally sensitive way (PELI-D), piloted and tested psychometrically. In terms of documentation quality, it is important that the preferences recorded by nursing staff are written down in the nursing record using PELI-D, plausibly based on the nursing process. AIM: To find out which preferences, assessed by the nursing staff in the pilot study with the PELI-D, were written down in the nursing record. METHODS: An exploratory document analysis was carried out. Included were 13 nursing records and five discussion participants from five institutions in three nursing settings. The data were evaluated descriptively and by a structuring content analysis. RESULTS: A total of 2% of the preferences, which were assessed with the PELI-D, were found in the nursing records and may be due to the use of PELI-D. Preferences mainly from the categories "interventions" and "biography" were found in the nursing record. CONCLUSIONS: 98% of the preferences assessed with the PELI-D were not written down. This can probably be attributed to the fact that the PELI-D was an "innovation" for the nursing staff. Therefore, the execution of an implementation study seems to be reasonable to improve the plausibility of the captured PELI-D data in the nursing documentation. In the context of this, it is also recommended to analyze how the PELI-D influences nursing processes and contents of the nursing record.


Assuntos
Registros de Enfermagem , Recursos Humanos de Enfermagem , Alemanha , Humanos , Casas de Saúde , Projetos Piloto
11.
Rev Lat Am Enfermagem ; 29: e3426, 2021.
Artigo em Inglês, Português, Espanhol | MEDLINE | ID: mdl-34037121

RESUMO

OBJECTIVE: to compare the quality of the Nursing process documentation in two versions of a clinical decision support system. METHOD: a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics. RESULTS: the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated. CONCLUSION: the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.


Assuntos
Sistemas de Apoio a Decisões Clínicas , Processo de Enfermagem , Brasil , Documentação , Humanos , Registros de Enfermagem , Planejamento de Assistência ao Paciente
12.
Comput Inform Nurs ; 39(11): 828-834, 2021 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-33990502

RESUMO

In Japan, nursing records are not easily put to secondary use because nursing documentation is not standardized. In recent years, electronic health records have necessitated the creation of Japanese nursing terminology. The purpose of this study was to develop and evaluate an automatic classification system for narrative nursing records using natural language processing technology and machine learning. We collected a week's worth of narrative nursing records from an academic hospital. The authors independently annotated the text data, dividing it into morphemes, the smallest meaningful unit in a language. During preprocessing when creating feature quantities, we used a Japanese tokenizer, MeCab, an open-source morphological parser, and the bag-of-words model. A support vector machine was adopted as a classifier for machine learning. The accuracy was 0.96 and 0.86 on the training set and test set, respectively, and the F value was 0.82. Our findings provide useful information regarding the development of an automatic classification system for Japanese nursing records using nursing terminology and natural language processing techniques.


Assuntos
Processamento de Linguagem Natural , Registros de Enfermagem , Registros Eletrônicos de Saúde , Eletrônica , Humanos , Japão , Aprendizado de Máquina
13.
Comput Inform Nurs ; 39(9): 492-498, 2021 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-33871385

RESUMO

This study aimed to analyze the importance and performance of nursing task items in the standard guidelines for comprehensive nursing services and confirm whether they are reflected in the nursing records. A total of 120 nurses from three hospitals were surveyed for the importance-performance analysis of standard nursing services and their correlation with nursing records. The average scores for importance, performance, and correlation to nursing records were 3.65, 3.31, and 3.08, respectively, demonstrating a significant positive correlation. Regarding the correlation between nursing tasks and nursing records, spiritual and emotional assessment, mobilization, education and counseling, and escaping and suicide prevention items had moderately low scores. In the importance correlation to the nursing records of the task items matrix, 10 items in quadrant 1 were strengths. Conversely, in quadrant 2, suicide and escape prevention require critical areas for improvement. The other six items were low-priority items in quadrant 3, and the three items in quadrant 4 were hygiene, elimination, and nutrition, which required excessive effort. It is necessary to evaluate the electronic nursing records system periodically according to the nursing environment and modify and supplement the records if required.


Assuntos
Enfermeiras e Enfermeiros , Registros de Enfermagem , Eletrônica , Humanos , Inquéritos e Questionários
14.
J Nurs Scholarsh ; 53(3): 306-314, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33720514

RESUMO

PURPOSE: The rapid implementation of electronic health records (EHRs) resulted in a lack of data standardization and created considerable difficulty for secondary use of EHR documentation data within and between organizations. While EHRs contain documentation data (input), nurses and healthcare organizations rarely have useable documentation data (output). The purpose of this article is to describe a method of standardizing EHR flowsheet documentation data using information models (IMs) to support exchange, quality improvement, and big data research. As an exemplar, EHR flowsheet metadata (input) from multiple organizations was used to validate a fall prevention IM. DESIGN: A consensus-based, qualitative, descriptive approach was used to identify a minimum set of essential fall prevention data concepts documented by staff nurses in acute care. The goal was to increase generalizable and comparable nurse-sensitive data on the prevention of falls across organizations for big data research. METHODS: The research team conducted a retrospective, observational study using an iterative, consensus-based approach to map, analyze, and evaluate nursing flowsheet metadata contributed by eight health systems. The team used FloMap software to aggregate flowsheet data across organizations for mapping and comparison of data to a reference IM. The FloMap analysis was refined with input from staff nurse subject matter experts, review of published evidence, current documentation standards, Magnet Recognition nursing standards, and informal fall prevention nursing use cases. FINDINGS: Flowsheet metadata analyzed from the EHR systems represented 6.6 million patients, 27 million encounters, and 683 million observations. Compared to the original reference IM, five new IM classes were added, concepts were reduced by 14 (from 57 to 43), and 157 value set items were added. The final fall prevention IM incorporated 11 condition or age-specific fall risk screening tools and a fall event details class with 14 concepts. CONCLUSION: The iterative, consensus-based refinement and validation of the fall prevention IM from actual EHR fall prevention flowsheet documentation contributes to the ability to semantically exchange and compare fall prevention data across multiple health systems and organizations. This method and approach provides a process for standardizing flowsheet data as coded data for information exchange and use in big data research. CLINICAL RELEVANCE: Opportunities exist to work with EHR vendors and the Office of the National Coordinator for Health Information Technology to implement standardized IMs within EHRs to expand interoperability of nurse-sensitive data.


Assuntos
Acidentes por Quedas/prevenção & controle , Documentação/métodos , Registros Eletrônicos de Saúde/normas , Modelos Teóricos , Registros de Enfermagem , Humanos , Padrões de Referência , Estudos Retrospectivos
15.
SMAD, Rev. eletrônica saúde mental alcool drog ; 17(1): 58-65, jan.-mar. 2021. ilus
Artigo em Português | LILACS, Index Psicologia - Periódicos | ID: biblio-1280641

RESUMO

OBJETIVO: conhecer as compreensões dos enfermeiros sobre humanização no cuidado em saúde mental. MÉTODO: trata-se de uma pesquisa exploratória, de abordagem qualitativa, realizada com 12 enfermeiros em um hospital psiquiátrico do interior do Nordeste, Brasil, no período de setembro de 2014 a março de 2015. Para a coleta de dados, utilizou-se entrevista semiestruturada, observação não participante e observação dos registros de Enfermagem, analisando-os a partir da Análise de Conteúdo de Bardin. RESULTADOS: emergiram quatro categorias: acolhimento, autonomia, protagonismo e corresponsabilidade. O cuidado humanizado aparece atrelado ao modelo manicomial, culminando em práticas focadas no uso da medicação, ações desarticuladas e sem participação do paciente no tratamento. A percepção da humanização é de dificuldade de atenção às pessoas em crises psíquicas, o que inviabiliza a produção do cuidado integral. CONCLUSÃO: o estudo contribui para a reflexão do cuidado de Enfermagem em saúde mental onde é preciso modificar as relações que o discurso biomédico mantém com os que buscam uma prática humanizada.


OBJECTIVE: to know nurses' understandings of humanization in mental health care. METHOD: it is an exploratory research, with a qualitative approach, carried out with 12 nurses in a psychiatric hospital in the interior of the Northeast, Brazil, from September 2014 to March 2015. For data collection, semi-structured interviews were used, non-participant observation and observation of Nursing records, analyzing them from Bardin's Content Analysis. RESULTS: four categories emerged: welcoming, autonomy, protagonism and co-responsibility. Humanized care appears linked to the asylum model, culminating in practices focused on the use of medication, disjointed actions and without patient participation in the treatment. The perception of humanization is of difficulty in caring for people in psychic crises, which makes the production of comprehensive care unfeasible. CONCLUSION:the study contributes to the reflection of nursing care in mental health where it is necessary to modify the relationships that biomedical discourse maintains with those who seek a humanized practice.


OBJETIVO: se objetivó conocer las comprensiones de los enfermeros sobre humanización en el cuidado en salud mental. MÉTODO: se trata de una investigación exploratoria de abordaje cualitativo realizada con 12 enfermeros en un hospital psiquiátrico del interior del Nordeste, Brasil, en el período de septiembre de 2014 a marzo de 2015. Para la recolección de datos se utilizó entrevista semiestructurada, observación no participante y observación de los registros de enfermería, analizados a partir del análisis de contenido de Bardin. RESULTADOS: se plantearon cuatro categorías: acogida, autonomía, protagonismo y corresponsabilidad. El cuidado humanizado aparece atado al modelo manicomial, culminando en prácticas enfocadas en el uso de la medicación, acciones desarticuladas y sin participación del paciente en el tratamiento. La percepción de la humanización es de dificultad de atención a las personas en crisis psíquicas que inviabiliza la producción del cuidado integral. CONCLUSIÓN: el estudio contribuye a la reflexión del cuidado de enfermería en salud mental donde, hay que modificar las relaciones que el discurso biomédico mantiene con los que buscan una práctica humanizada.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Participação do Paciente , Registros de Enfermagem , Humanização da Assistência , Acolhimento , Hospitais Psiquiátricos , Enfermeiras e Enfermeiros , Cuidados de Enfermagem , Enfermagem Psiquiátrica
16.
Pflege ; 34(2): 92-102, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33535840

RESUMO

Effects of Guided Clinical Reasoning on the Advanced Nursing Process quality - An experimental intervention study Abstract. Background: The correctly applied Advanced Nursing Process leads demonstrably to more accurate nursing diagnoses and better nursing outcomes. It requires nurses' knowledge, clinical decision-making competency, and a positive attitude. Former Guided Clinical Reasoning (GCR) trainings significantly enhanced the Advanced Nursing Process quality. However, the congruence between nursing records, care situations, and patient interviews was not yet investigated. Research question: Which effects has GCR on nurses' knowledge, attitude, clinical performance, and on the quality of the Advanced Nursing Process? Methods: An experimental intervention study was carried out from 2016 until 2018 in a Swiss hospital. The 5-month intervention contained four seminar days and GCR-case meetings and was investigated by an evaluation model (n = 95 nurses, n = 24 patients, n = 225 nursing records). Results: After GCR training, nurses showed greater knowledge (p < 0,0001) and a more positive attitude (p = 0,004) on the Advanced Nursing Process than the control group. The congruence of nursing diagnoses, interventions, and outcomes between observations, interviews, and nursing records was higher in the intervention group. At the last measurement point, nursing diagnoses were stated significantly more accurate, interventions were more effective, and better patient outcomes were achieved (all p < 0,0005). Conclusions: GCR trainings should be used to enhance the Advanced Nursing Process quality, so that based on more accurate nursing diagnoses better patient outcomes are achieved.


Assuntos
Prática Avançada de Enfermagem , Raciocínio Clínico , Processo de Enfermagem , Humanos , Diagnóstico de Enfermagem , Pesquisa em Avaliação de Enfermagem , Registros de Enfermagem
17.
Int Nurs Rev ; 68(3): 328-340, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33539567

RESUMO

AIMS: (1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self-care requisites. BACKGROUND/INTRODUCTION: Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions. METHODS: A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results. RESULTS: From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting. CONCLUSION: Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs. IMPLICATIONS FOR NURSING PRACTICE: Representation of most relevant nursing diagnoses within the scope of universal self-care requisites. IMPLICATIONS FOR HEALTH POLICY: Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.


Assuntos
Cuidados de Enfermagem , Diagnóstico de Enfermagem , Documentação , Humanos , Registros de Enfermagem , Portugal , Autocuidado
18.
Jpn J Nurs Sci ; 18(2): e12403, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33448157

RESUMO

AIM: This study was carried out to analyze nursing care provided to patients on high and low fall-risk days and to evaluate the effectiveness of nursing care in terms of preventing falls. METHODS: A retrospective review of medical records was conducted for patients admitted to a tertiary hospital in Korea. General and clinical information, fall occurrences, Hendrich II Fall Risk Model (HFRM II) fall-risk assessment scores, nursing care related to fall prevention, and medications administered were extracted. RESULTS: Data from 43,267 days of records for 11,718 patients were analyzed. Nursing assessment, intervention, and administration of medication were provided more frequently on high fall-risk days than on low fall-risk days. Analysis performed on the entire cohort days showed fall occurrence was significantly associated with infrequent mobility assessment and greater usage of anti-anxiety agents. On high fall-risk days, fall occurrence was related to less restraint assessment and greater usage of vessel dilatators. CONCLUSIONS: The implementation of risk-targeted interventions for fall prevention based on fall-risk assessment is needed. For general fall prevention, assessment of patients' mobility should be strengthened. For high fall-risk patients, it may be more effective for nurses to focus on assessing restraints, evaluating medication records, and withdrawing medications related to falls.


Assuntos
Acidentes por Quedas , Registros de Enfermagem , Acidentes por Quedas/prevenção & controle , Humanos , República da Coreia , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Centros de Atenção Terciária
19.
Nurs Open ; 8(3): 1463-1478, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33476490

RESUMO

AIM: As the risk for malnutrition in older people in hospitals is often underreported, we aimed to develop a risk nursing diagnosis, including label, definition and risk factors. DESIGN: A convergent parallel mixed-methods design was employed. METHODS: A literature review led to risk factors, validated by 22 hospitalized older people's perspectives and observations, including their nursing records. Per participant, one interview (qualitative), one non-participatory observation of three meals (198 hr; qualitative) and one nursing record evaluation (quantitative) were conducted. FINDINGS: According to the classification system of NANDA International, the risk for protein-energy malnutrition is defined with 18 risk factors, including associated conditions. Content validated risk factors are presented from three participants with the most, medium and least coherent nursing record, measured with the Quality of Diagnosis, Intervention and Outcomes tool. CONCLUSION: This new nursing diagnosis supports nurses to manage the risk for malnutrition and optimize older people's nutrition.


Assuntos
Desnutrição , Processo de Enfermagem , Idoso , Humanos , Desnutrição/diagnóstico , Diagnóstico de Enfermagem , Registros de Enfermagem , Estado Nutricional
20.
J Clin Nurs ; 30(1-2): 56-71, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33113237

RESUMO

BACKGROUND: Inpatient nursing documentation facilitates multi-disciplinary team care and tracking of patient progress. In both high- and low- and middle-income settings, it is largely paper-based and may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed. OBJECTIVE: To synthesise evidence on how paper-based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care. DESIGN: A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA-ScR guidelines. ELIGIBILITY CRITERIA: We included studies that described the process of designing paper-based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019. SOURCES OF EVIDENCE: PubMed, CINAHL, Web of Science and Cochrane supplemented by free-text searches on Google Scholar and snowballing the reference sections of included papers. RESULTS: 12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges. CONCLUSIONS: The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human-centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Paper-based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation.


Assuntos
Documentação , Registros de Enfermagem , Adolescente , Adulto , Idoso , Austrália , Criança , Registros Eletrônicos de Saúde , Feminino , Hospitais , Humanos , Recém-Nascido , Masculino
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