Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 7.276
Filtrar
1.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 12: 12-19, jan.-dez. 2020. tab
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1047786

RESUMO

Objetivo: o estudo objetivou identificar quais estratégias estão sendo utilizadas na implementação de registros eletrônicos relacionados ao processo de enfermagem, nas bases de dados: PubMed, Scopus e Web of Science. Método: trata-se de uma revisão integrativa na qual os descritores utilizados foram electronic health records e nursing process. Resultados: Os dados encontrados indicam que os estudos em sua maioria foram pesquisas quantitativas, publicadas no periódico Nursing informatics (Studies in Health Technology and Informatics) desenvolvidas em universidades e no continente americano. Conclusão: os dados apontam que a maior parte das pesquisas são referentes a usabilidade do registro eletrônico em saúde. Outros aspectos abordados foram as fragilidades e perspectivas associados ao uso do registro eletrônico, bem como o processo de enfermagem em sistemas informatizados


Objective: the objective of this study was to identify which strategies are being used in the implementation of electronic records related to the nursing process, in PubMed, Scopus and Web of Science databases. Method: this is an integrative review in which the descriptors used were electronic health records and nursing process. Results: the data found indicate that the studies were mostly quantitative research, published in the journal Nursing informatics (Studies in Health Technology and Informatics) developed in universities and in the American continent. Conclusion: the data indicate that most of the researches are referring to the usability of electronic health records. Other aspects addressed were the weaknesses and perspectives associated with the use of electronic registration, as well as the nursing process in computerized systems


Objetivo: el estudio tuvo como objetivo identificar qué estrategias están siendo utilizadas en la implementación de registros electrónicos relacionados al proceso de enfermería, en las bases de datos: PubMed, Scopus y Web of Science. Métodos: se trata de una revisión integrativa en la cual los descriptores utilizados fueron electronic health records y kind process. Resultados: los datos encontrados indican que los estudios en su mayoría fueron investigaciones cuantitativas, publicadas en el periódico Nursing informatics (Studies in Health Technology and Informática) desarrolladas en universidades y en el continente americano. Conclusiones: los datos apuntan que la mayor parte de las encuestas son referentes a la usabilidad del registro electrónico en salud. Otros aspectos abordados fueron las fragilidades y perspectivas asociadas al uso del registro electrónico, así como el proceso de enfermería en sistemas informatizados


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Registros de Enfermagem , Registros Eletrônicos de Saúde/instrumentação , Processo de Enfermagem , Alfabetização Digital , Educação Continuada em Enfermagem
2.
Rev. Esc. Enferm. USP ; 53: e03471, Jan.-Dez. 2019. tab
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1020378

RESUMO

RESUMO Objetivo Identificar a prevalência de documentação do Processo de Enfermagem nos hospitais e ambulatórios administrados pela Secretaria de Estado da Saúde de São Paulo. Método Estudo descritivo, realizado por meio de entrevistas com enfermeiros responsáveis por 416 setores de 40 instituições sobre a documentação de quatro fases do Processo de Enfermagem (levantamento de dados, diagnóstico, prescrição e evolução) e de anotações de enfermagem. Resultados Dos 416 setores estudados, 89,9% documentavam pelo menos uma fase; 56,0% documentavam as quatro fases; 4,3% documentavam apenas anotações de enfermagem; 5,8% não documentavam nenhuma fase, nem as anotações de enfermagem. Os tipos de setores que menos documentavam foram: ambulatório, apoio diagnóstico, centro cirúrgico e centro obstétrico; os que mais documentavam: unidades de terapia intensiva, prontos-socorros e unidades de internação. O levantamento de dados e o diagnóstico foram as fases menos documentadas, ambas em 78,8% dos setores. Conclusão A maior parte dos setores estudados documenta o Processo de Enfermagem e faz anotações de enfermagem, mas há setores em que a documentação não corresponde às exigências formais. A viabilidade da documentação de todas as fases do Processo de Enfermagem em determinados tipos de setores precisa ser mais bem estudada.


RESUMEN Objetivo Identificar la prevalencia de documentación del Proceso de Enfermería en los hospitales y ambulatorios administrados por la Secretaría de Estado de la Salud de São Paulo. Método Estudio descriptivo, llevado a cabo mediante entrevistas con enfermeros responsables de 416 sectores de 40 centros acerca de la documentación de cuatro fases del Proceso de Enfermería (inventario de datos, diagnóstico, prescripción y evolución) y de apuntes de enfermería. Resultados De los 416 sectores estudiados, el 89,9% documentaban por lo menos una fase; el 56,0% documentaban las cuatro fases; el 4,3% documentaban solo apuntes de enfermería; el 5,8% no documentaban ninguna fase, ni los apuntes de enfermería. Los tipos de sectores que menos documentaban fueron: ambulatorio, apoyo diagnóstico, quirófano y centro obstétrico; los que más documentaban: unidades de cuidados intensivos, urgencias y unidades de estancia hospitalaria. El inventario de datos y el diagnóstico fueron las bases menos documentadas, ambas en el 78,8% de los sectores. Conclusión La mayor parte de los sectores estudiados documenta el Proceso de Enfermería y hace apuntes de enfermería, pero hay sectores en los que la documentación no corresponde a los requerimientos formales. La factibilidad de la documentación de todas las fases del Proceso de Enfermería en determinados tipos de sectores necesita ser más bien estudiada.


ABSTRACT Objective To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health. Method A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations. Results Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors. Conclusion Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.


Assuntos
Registros de Enfermagem , Padrões de Prática em Enfermagem , Processo de Enfermagem , Serviços de Enfermagem
3.
Rev. Pesqui. (Univ. Fed. Estado Rio J., Online) ; 11(5): 1226-1235, out.-dez. 2019. ilus
Artigo em Inglês, Português | LILACS, BDENF - Enfermagem | ID: biblio-1022343

RESUMO

Objetivo: Analisar a percepção dos enfermeiros sobre a implantação e o uso do Prontuário Eletrônico do Cidadão (PEC) no cuidado de enfermagem. Método: Pesquisa de abordagem qualitativa realizada com 11 enfermeiros da Atenção Básica. Resultados: Emergiram três categoriais: O Prontuário Eletrônico do Cidadão sob a ótica dos enfermeiros da Atenção Básica (AB); A Implantação do Prontuário Eletrônico do Cidadão nas Unidades de Atenção Básica (UBS); Contribuições e desafios na utilização do PEC para o cuidado de enfermagem. Identificou-se que PEC é uma ferramenta que pode contribuir para a melhoria do funcionamento das UBS e para a qualificação do cuidado de enfermagem.Conclusão: O PEC colabora nos processos de trabalho do enfermeiro no assistir, administrar e pesquisar. Para funcionamento do PEC nas UBS é preciso implementar suporte e manutenção da rede lógica e internet; capacitação dos profissionais no uso da informática e organização de educação permanente


Objective: The study's purpose has been to analyze the nurses' viewpoint regarding both implementation and use of the Electronic Citizen Record (ECR) in nursing care. Methods: It is a descriptive research with a qualitative approach that was carried out with 11 nurses from the primary health care service. Results: The following three categories appeared: The ECR from the primary care nurses' viewpoint; Implementation of the ECR in the basic health units; Contributions and challenges by using the ECR for nursing care. It was identified that the ECR is a tool that can contribute to the improvement of basic health units functioning, as well as, to the nursing care qualification. Conclusion: The ECR collaborates in the nurses' work processes by assisting, administering and researching. In order to make sure the ECR functioning in basic health units, it is necessary to implement support and maintenance of the logical network and internet; to promote training for health professionals using data processing, and also organizing the permanent education activity


Objetivo: Analizar la percepción de los enfermeros sobre la implantación y el uso del registro electrónico del ciudadano (REC) en la atención de enfermería.Método: Investigación de enfoque cualitativo realizada com 11 enfermeras . Resultados: Surgieron tres categorias: REC bajo la percepción de losenfermeros de Atención Primária de Salud; implantación del REC em las Unidades de Atención Primária (UNAPS); contribuciones y desafios em la utilización del REC en la atención de enfermería. Se identifico que REC es uma herramienta que podrá contribuir para lamejoría del funcionamento de las UNAPS y para la cualificación de La atención de enfermería.Conclusión: El REC colabora en los procesos de trabajo del enfermero en el asistir, administrar e investigar.Para el funcionamento del REC es necessariosoporte y manutención de lared lógica y del internet; capacitación de losprofissionalesen informática y organización de educación permanente


Assuntos
Humanos , Feminino , Adulto , Pessoa de Meia-Idade , Atenção Primária à Saúde , Registros de Enfermagem , Registros Eletrônicos de Saúde/instrumentação , Alfabetização Digital , Educação Continuada , Processo de Enfermagem
4.
Enferm. intensiva (Ed. impr.) ; 30(3): 135-143, jul.-sept. 2019. ilus, graf, tab
Artigo em Espanhol | IBECS | ID: ibc-182972

RESUMO

Objetivos: Determinar la incidencia y categoría más incidente de úlceras por presión (UPP). Conocer las características clínicas de las UPP. Determinar si se realiza un registro adecuado de UPP y las medidas de prevención utilizadas. Método: Estudio observacional, descriptivo y retrospectivo realizado durante el año 2014 en la UCI del Hospital Universitario Araba (HUA)-Txagorritxu. La población de estudio fueron todos los pacientes ingresados con UPP, obtenidos mediante muestreo accidental. Los datos se recogieron a través de los registros informatizados del programa Metavisión de valoración del riesgo, valoración clínica y tratamiento de UPP, los cuales se analizaron con estadística descriptiva y se procesaron mediante el paquete estadístico SPSS, versión 22.0. El estudio fue aprobado por el Comité Ético de Investigaciones Clínicas del HUA. Resultados: La incidencia de pacientes con UPP durante el 2014 alcanzó el 6,78%. La localización de UPP más frecuente fue en la zona sacra y en los talones. La categoría de UPP más incidente fue la II, seguida de la I. De las 98 UPP tratadas en nuestros pacientes, 43 se produjeron fuera del servicio y 55 en la UCI del HUA. La ausencia de registro, en todas las variables descritas sobre las UPP, fue de un 19,01%. Conclusiones: La incidencia de UPP alcanzó un porcentaje inferior a lo existente en la literatura actual. La categoría, localización y características clínicas más frecuentes se asimilan a estudios previos. Existe una elevada tasa de no registro de las características de las UPP declaradas. Se efectuaron unas buenas medidas de prevención de UPP y registro de las mismas


Objectives: The aim of this paper is to determine the incidence and most incident pressure ulcers (PU) category. Establish the main clinical characteristics of these PU. Determine whether there is adequate documentation of PU and of the measures used to prevent them. Method: Observational descriptive and retrospective study during 2014 at Intensive Care Unit (ICU)-University Hospital of Araba. Study sample, all patients suffering from PU at the time of the study by accidental sampling. Computerised records regarding risk assessment, clinical assessment and pressure sore treatment, provided by the 'Metavision' computer programme and descriptive statistics using SPSS version 22.0. Approval from the Ethics Committee for Clinical Research of the University Hospital of Araba was obtained. Results: The incidence of patients suffering from PU during 2014 was 6.78%. The most common locations for PU were the sacral region and the heels: the most incident pressure ulcers category was grade II, followed by grade I. Out of the 98 PU treated in our patients, 43 occurred outside the ICU and 55 in the unit itself. The lack of records, in all the variables described about PU, was 19.10%. Conclusions: The incidence of pressure ulcers was lower than in the current literature. The most frequent category, location and clinical characteristics are comparable to previous studies. There is a high rate of failing to record the characteristics of the PU declared. Good PU prevention measures and recording were carried out


Assuntos
Humanos , Idoso , Lesão por Pressão/epidemiologia , Lesão por Pressão/prevenção & controle , Registros de Enfermagem , Controle de Formulários e Registros , Unidades de Terapia Intensiva , Estudos Retrospectivos , Análise de Dados
5.
Rev Esc Enferm USP ; 53: e03471, 2019 Aug 19.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31433013

RESUMO

OBJECTIVE: To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health. METHOD: A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations. RESULTS: Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors. CONCLUSION: Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.


Assuntos
Documentação/estatística & dados numéricos , Processo de Enfermagem/normas , Registros de Enfermagem/normas , Instituições de Assistência Ambulatorial/normas , Brasil , Estudos Transversais , Serviço Hospitalar de Emergência/normas , Hospitais/normas , Humanos , Unidades de Terapia Intensiva/normas , Entrevistas como Assunto , Saúde Pública
6.
Stud Health Technol Inform ; 264: 1061-1064, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438087

RESUMO

Hospitalization expenses account for a high rate of national medical care expenditure in Japan. The Japanese national medical care expenditure was 42 trillion 364.4 billion yen in 2015, in which hospitalization expenses were 15 trillion 575.2 billion yen (36.8%). Therefore, it is necessary to take measures to reduce hospitalization expenses. The total ratio of the labor cost of physicians and nurses accounted for about 1/3 of all expenditures of general hospitals in 2015. Moreover, the personnel cost of nurses accounted for about 1/5 of all expenditure, showing that the personnel cost of nurses is an element with a large influence on hospital management. The objective of this study was to develop a methodology to reduce the overtime work of nurses accounting for a large rate of personnel expenses by focusing on overtime work, a personnel expense-increasing factor, aiming at hospital cost reduction. First, the cause of overtime work, planning, and recording by nurses were analyzed and an IT application increasing the quality and efficiency of the work was developed. Then, fees for the use and maintenance of the IT system meeting the following conditions were set as a strategy to introduce the system: (1) 50% reduction of the overtime work of nurses and (2) fees 50% or lower than the reduced payment for overtime work. This IT application was introduced to the heads and directors of nursing of 5 hospitals and the strategy was proposed. All heads and directors highly evaluated the system and responded to initiate the process for the introduction. It was suggested that the methodology to reduce the overtime work of nurses proposed by this study is useful and feasible.


Assuntos
Gastos em Saúde , Registros de Enfermagem , Custos e Análise de Custo , Assistência à Saúde , Humanos , Japão
7.
Rev. enferm. Inst. Mex. Seguro Soc ; 27(3): 175-181, Jul-Sep 2019. tab, graf
Artigo em Espanhol | LILACS, BDENF - Enfermagem | ID: biblio-1047309

RESUMO

El registro clínico de enfermería debe reflejar de forma concreta y precisa la actuación del profesional en la atención del paciente. Por ello, resulta importante contar con instrumentos que evalúen la documentación de enfermería y permitan la mejora del cuidado a partir de la continuidad y la calidad de este. El presente estudio describe el proceso de diseño y validación de un instrumento para evaluar los registros de enfermería. Estuvo conformado por cuatro fases que dieron como resultado la Cédula de Evaluación del Registro Clínico de Enfermería (CERCE), constituida por 48 reactivos de tipo dicotómico, divididos en seis indicadores, la cual reporta un coeficiente global de confiabilidad Kuder-Richardson (KR-20) de 0.917 y cuyos indicadores oscilaron entre 0.77 y 0.93. El producto final representa los esfuerzos para la mejora de los procesos de evaluación de los registros de enfermería como una medida que contribuya a una gestión de la calidad del cuidado.


The nursing record should reflect in a concrete and accurate way the performance of the nursing professional in care of the patient. That is why it is important to have instruments to evalúate the nursing documentation and allow the improvement of care through keeping a good nursing record. This study describes the process of design and validation of an instrument to evalúate nursing records. This instrument comprised four phases that resulted in the Evaluation Card of the Clinical Nursing Registry (CERCE, according to its initials in Spanish), consisting of 48 dichotomous items, divided into six indicators, reporting a Kuder- Richardson reliability coefficient (KR-20) of 0.917, and whose indicators ranged from 0.77 to 0.93. The final product represents the efforts to improve the evaluation processes of nursing records as a measure aimed at the management of quality of care.


Assuntos
Humanos , Registros de Enfermagem , Enfermagem , Gestão da Qualidade , Avaliação em Enfermagem , Cuidados de Enfermagem , México
8.
Enferm. foco (Brasília) ; 10(3): 28-33, jul. 2019. tab
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1049778

RESUMO

Objetivo: Analisar a qualidade dos registros de enfermagem em prontuários. Metodologia: Pesquisa descritiva, quantitativa realizada em um hospital universitário de Salvador, Bahia, Brasil, entre setembro de 2017 e maio de 2018, a partir de indicadores de qualidade dos registros de enfermagem em prontuários. Utilizou-se um instrumento estruturado para a coleta dos dados. A análise foi do tipo descritiva; utilizou-se a frequência absoluta e relativa dos indicadores. Resultados: Dentre os 203 prontuários analisados, o percentual de identificação correta dos pacientes, com nomes completos e número de prontuário foi acima de 90%. Houve fragilidade na checagem das prescrições médica e de enfermagem, assim como na justificativa para a não checagem de itens prescritos. Conclusão: A qualidade dos registros de enfermagem atende parcialmente às recomendações do Conselho Federal de Enfermagem. Os resultados sugerem necessidade de constante atuação dos programas educacionais para o fortalecimento de ações que visem a excelência dos registros de enfermagem. (AU)


Objective: To analyze the quality of the nursing records on patients' records. Methodology: A descriptive study of a quantitative approach performed in a university hospital of Salvador, Bahia, Brazil, between the months of September 2017 and May 2018, from quality indicators of the nursing registers on patients' records. A structured instrument was used for data collection. The analysis was descriptive; it was used the absolute and relative frequency of the indicators. Result: Among the 203 patients' records analyzed, the percentage of correct identification of patients, with full name and number of the clinical record was of over 90%. Nevertheless, there was a weakness in checking medical and nursing prescriptions, as well as in the justification for not checking prescribed items. Conclusion: The quality of the nursing registers partially follows the recommendations of the Federal Council of Nursing. The results suggest the need for constant practice of educational programs for strengthening actions towards performing nursing registers with excellency. (AU)


Objetivo: Analizar la calidad de registros de enfermería en historiales. Metodología: Pesquisa descriptiva, con abordaje cualitativa realizada en un hospital universitario de Salvador, Bahia, Brasil, entre los meses de septiembre de 2017 y mayo de 2018, a partir de indicadores de cualidad de los registros de enfermería en historiales clínicos. Se utilizó un instrumento estructurado para la colecta de datos. El análisis fue descriptivo; fue usado la frecuencia absoluta y relativa de los indicadores Resultados: De entre los 203 historiales analizados, el porcentaje de identificación correcta de los pacientes, con nombres completos y número de historial fue superior a 90%. Sin embargo, hubo debilidad en el chequeo de las prescripciones médicas y de enfermería, al igual que en la justificativa para el no chequeo de ítems prescritos. Conclusión: La calidad de los registros de enfermería atiende parcialmente a las recomendaciones del Consejo Federal de Enfermería. Los resultados sugieren una necesidad de constante actuación de los programas educacionales para el fortalecimiento de acciones que tengan por objeto la realización de registro de enfermería con excelencia. (AU)


Assuntos
Auditoria de Enfermagem , Qualidade da Assistência à Saúde , Registros de Enfermagem , Enfermagem , Educação Continuada
9.
Rev. enferm. UFSM ; 9: [15], jul. 15, 2019.
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1024464

RESUMO

Objetivo: analisar os registros de acadêmicos de enfermagem sobre o procedimento de punção venosa periférica com cateter agulhado. Método: estudo descritivo, quantitativo, realizado com 76 acadêmicos de enfermagem do 5º ao 9º período de uma universidade pública, entre fevereiro e maio de 2014. Para coleta de dados desenvolveu-se cenário simulado com manequim, sendo avaliado o registro do procedimento mediante instrumento estruturado. Realizada análise descritiva. Resultados: quanto às fragilidades, 100,0% dos alunos não realizaram o registro sobre fixação do cateter; predominou ausência da informação sobre intercorrências (87,3%), dispositivo utilizado (85,7%) e motivo da punção (84,1%). Sobre os registros adequados, as variáveis data, hora e identificação sobressaíram positivamente. Conclusões: identificaram-se discrepâncias relacionadas ao registro da técnica, com ausência de informações essenciais e incompletas. Destaca-se a necessidade de trabalhar a temática em associação teoria e prática, com foco no desenvolvimento de competências no âmbito do ensino e assistência de enfermagem


Aim: To analyze undergraduated nursing students records on needle catheter peripheral venous puncture. Method: Quantitative, descriptive study, enrolled 76 undergraduated nursing students at a public university, from february through march 2014. Data collecting took place at simulated scenario and procedure records were taken with structured instrument. Descriptive analysis performed. Results: About fragilities, 100% of the students did not make catheter fixation notes; adverse events information (87,3%), used device (85%) and puncture reason (84,1%) were predominantly absent. Adequate date, time and identification records were positive highlights. Conclusion: Technique registration discrepancies were identified, with essential information absent or incomplete. Subject matter should be worked in association between theory and practice, focusing competence development at teaching environment and nursing assistance locations.


Objetivo: analizar los registros de estudiantes de enfermería sobre la punción venosa periférica con catéter con aguja. Método: investigación descriptiva y cuantitativa con 76 estudiantes de enfermería de una universidad pública desde febrero hasta mayo, 2014. Para la recolección de datos, se desarrolló un escenario simulado con maniquí. Y el registro del procedimiento se evaluó con un instrumento estructurado. Se realizó el análisis descriptivo. Resultados: en cuanto a las debilidades, el 100% de los estudiantes no registraron la fijación del catéter; predominaron la ausencia de información sobre complicaciones (87,3%), el dispositivo utilizado (85,7%) y el motivo de la punción (84,1%). En cuanto a los registros apropiados, las variables fecha, hora e identificación se destacaron positivamente. Conclusiones: hubo discrepancias relacionadas con el registro de la técnica y ausencia de información esencial e incompleta. Destacamos la necesidad de trabajar el tema en asociación de la teoría y la práctica, con foco en el desarrollo de competencias en la enseñanza y la atención de enfermería.


Assuntos
Humanos , Estudantes de Enfermagem , Cateterismo Periférico , Registros de Enfermagem , Avaliação em Enfermagem
10.
Nursing (Säo Paulo) ; 22(254): 3039-3042, jul.2019.
Artigo em Português | LILACS, BDENF - Enfermagem | ID: biblio-1025927

RESUMO

Estudo descritivo e qualitativo, com o objetivo de analisar a percepção dos enfermeiros de um hospital público do município de Belém, acerca de possíveis dificuldades, para elaboração de evoluções escritas. O estudo foi realizado no mês de setembro de 2016, nas clínicas cirúrgica e no 2° Departamento de Câncer, de um hospital-escola, referência em oncologia, localizado no município de Belém/PA. Os participantes do estudo foram oito enfermeiras, entrevistadas a partir de um roteiro semiestruturado. A análise dos dados se deu através da análise de conteúdo, emergindo três categorias temáticas. As dificuldades concentram-se, principalmente, na declaração da falta de tempo, potencialmente decorrente da realização de outras atividades além das de cuidado, e agravada pelo reduzido número de profissionais, o que pode refletir na perda de informações sobre os resultados dos cuidados prestados e da avaliação de sua qualidade, e priorização de atividades administrativas. Conclui-se que, de acordo com os participantes do estudo, a falta de tempo é o principal fator dificultador para a realização da evolução de enfermagem em todos os aspectos que deve contemplar.(AU)


Descritive and qualitative research, with the objetive to analyse the nurses perception of a public hospital in the city of Belém about the possible difficulties to elaborate written evolutions. The study was performed in September 2016, in the surgical clinics and in the 2nd Cancer Department, of a school hospital, reference in oncology, located in Belém/PA. The research's participants were eight nurses, interviewed from a semi-structured script. Data analysis was made through content analysis, originating three tematic categories. The difficulties concentrate, mainly, in alegation of lack of time, which is potentially due to activities other than care, and aggravated by the reduced number of professionals, which may reflect the loss of information about the care outcomes and the evaluation of its quality, and prioritization of administrative activities. It is concluded that, according to the participants of the study, the lack of time is the main obstacle to the achievement of the nursing record in all aspects that should contemplate.(AU)


Estudio descriptivo y cualitativo, con el objetivo de analizar la percepción de los enfermeros de un hospital público del municipio de Belém, acerca de posibles dificultades, para la elaboración de evoluciones escritas. El estudio fue realizado en el mes de septiembre de 2016, en las clínicas quirúrgicas y en el 2° Departamento de Cáncer, de un hospital-escuela, referencia en oncología, localizado en el municipio de Belém / PA. Los participantes del estúdio fueron ocho enfermeras, entrevistadas a partir de un itinerario semiestructurado. El análisis de los datos se dio a través del análisis de contenido, emergiendo tres categorías temáticas. Las dificultades se concentran principalmente en la declaración de la falta de tiempo, potencialmente derivada de la realización de otras actividades además de las de cuidado, y agravada por el reducido número de profesionales, lo que puede reflejar en la pérdida de informaciones sobre los resultados de los cuidados prestados y de la evaluación de su calidad, y priorización de actividades administrativas. Se concluye que, de acuerdo con los participantes del estudio, la falta de tiempo es el principal factor dificultador para la realización de la evolución de enfermería en todos los aspectos que debe contemplar.(AU)


Assuntos
Humanos , Registros de Enfermagem , Auditoria de Enfermagem , Processo de Enfermagem
11.
Rev Gaucha Enferm ; 40(spe): e20180341, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31038606

RESUMO

OBJECTIVE: To analyze the registry of the Transfer Note (NT) and the emission of the Modified Early Warning Score (MEWS) performed by the nurse in adult patients transferred from the Emergency Service as an effective communication strategy for patient safety. METHOD: A cross-sectional retrospective study developed at a teaching hospital in the South of Brazil that evaluated 8028 electronic medical records in the year 2017. A descriptive analysis was performed. RESULTS: NT reached the institutional target of 95% in January and February, falling below the target in other months. The MEWS measurement was performed in 85.6% (n = 6,870) of the medical records. Of these patients, 96.8% (n = 6,652) had unchanged MEWS. CONCLUSION: NT and MEWS are inserted in the work of the nurse, however, actions are needed to qualify patient safety, improving effective communication and therefore reducing the possibility of occurrence of adverse events.


Assuntos
Sistemas de Comunicação no Hospital , Registros Hospitalares , Avaliação em Enfermagem , Registros de Enfermagem , Segurança do Paciente , Transferência de Pacientes/organização & administração , Gestão de Riscos/métodos , Índice de Gravidade de Doença , Adulto , Brasil , Estudos Transversais , Registros Eletrônicos de Saúde , Serviço Hospitalar de Emergência , Controle de Formulários e Registros , Sistemas de Comunicação no Hospital/organização & administração , Hospitais de Ensino/organização & administração , Humanos , Papel do Profissional de Enfermagem , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Medição de Risco , Gestão de Riscos/organização & administração
12.
Rev Gaucha Enferm ; 40(spe): e20180398, 2019.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31038610

RESUMO

OBJECTIVE: Describe the implementation of care transfer flow chart in postoperative, based on a risk classification model. METHOD: Experience report on the implementation of a pilot project between the post-anesthetic recovery room and the surgical hospitalization unit, developed between December/2016 and March/2017, aimed at transferring s the care of patients with low risk of postoperative mortality, in a university hospital in the South of Brazil. RESULTS: The project made it possible to expedite the discharge of the patient from the Post-Anesthetic Recovery Room to the surgical hospitalization unit, to qualify the records regarding nursing care and to optimize the time of nurses in both units for care activities. CONCLUSION: The implementation of a care transfer flow chart from the risk classification for postoperative patients contributed to a more effective communication, culminating in improvements in patient safety.


Assuntos
Transferência de Pacientes , Cuidados Pós-Operatórios , Brasil , Registros Hospitalares , Unidades Hospitalares , Hospitais Universitários/organização & administração , Humanos , Registros de Enfermagem , Transferência de Pacientes/métodos , Projetos Piloto , Cuidados Pós-Operatórios/mortalidade , Cuidados Pós-Operatórios/enfermagem , Sala de Recuperação , Risco , Desenho de Programas de Computador
13.
Int J Med Inform ; 127: 120-126, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31128823

RESUMO

BACKGROUND: This article seeks to facilitate the re-imagining of nursing records purposefully within an electronic context. It questions existing approaches to nursing documentation, critically examines existing nursing record systems and identifies new requirements. METHODS: A comprehensive literature review was conducted to identify themes, that might meaningfully contribute to a new approach to nursing record systems development, around four key interrelated areas - standards, decision making, abstraction and summarization, and documenting. Studies were analyzed using narrative synthesis to provide a critical analysis of the current 'state of the art', and recommendations for the future. RESULTS: Included studies collectively described aspects of current best practice, both in terms of nursing record systems themselves, and how nurses and other health professionals contribute to and engage with those systems. A number of cross-cutting themes identified more novel approaches taken by nurses to systems development: going back to basics in determining purpose; firming up informatics foundations; nuancing or tailoring to suit different requirements; and engagement, involvement and participation. CONCLUSION: There is a paucity of research that specifically focuses on the nature of the electronic nursing record and its impact on patient care processes and outcomes. In addition to further research in these areas, there is a need: to reinterpret nurses as knowledge workers rather than as 'data collectors'; to agree on the application in practice of appropriate standards and terminologies; and to work together with system developers to change the ways in which data are captured and care is documented.


Assuntos
Registros de Enfermagem , Coleta de Dados , Tomada de Decisões , Registros Eletrônicos de Saúde , Pessoal de Saúde , Humanos
14.
J Clin Nurs ; 28(15-16): 2990-3000, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30938871

RESUMO

AIMS AND OBJECTIVES: To evaluate whether implementing the Modified Early Warning Scoring system impacts nurses' free text notes related to Airway, Breathing, Circulation and Pain in general ward medical and surgical patients. BACKGROUND: The quality of nursing documentation in patient health records is important to secure patient safety, but faces multiple challenges whether being paper-based or electronic. Nurses' ability to draw a complete picture of the patient situation is thereby compromised. Structured use of the Modified Early Warning Score, found to reduce unexpected death, might affect nurses' free text documentation of clinical observations. DESIGN: A prospective, pre- and postinterventional, nonrandomised study adhering to the EQUATOR guideline TREND. METHODS: Data on nurses' free text notes were obtained in 1,497 patient records during one preinterventional (March-June 2009) and two postinterventional study periods (September-December 2010 and March-June 2011) in a Danish university hospital. Data were organised by the Airway, Breathing and Circulation principles and by nurses' working shifts in the 56 hr surrounding the first recording of deviating vital parameters or a Modified Early Warning Score ≥ 2. Preinterventional free text notes were compared with notes from the two postinterventional periods, respectively. RESULTS: In the 8-hr working shift where deviations in vital parameters were recorded for the first time, nurses' free text notes related to patients' breathing (B) increased significantly, comparing 2009 with 2010 and 2011, respectively. In the 24 hr following initial deviations in vital parameters, a significant increase in free text notes was identified concerning Airway, Breathing and Circulation-related symptoms or problems. CONCLUSION: Mandatory use of the Modified Early Warning Score and related implementation activities significantly impacts nursing documentation of free text notes. RELEVANCE TO CLINICAL PRACTICE: Nurses' practice of communicating observed clinical symptoms by documenting free text notes should be supported through measures to enhance situation awareness.


Assuntos
Registros de Enfermagem/normas , Recursos Humanos de Enfermagem no Hospital/normas , Segurança do Paciente/normas , Adulto , Estudos Controlados Antes e Depois , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Estudos Prospectivos , Medição de Risco/métodos
15.
San Salvador; s.n; mar. 2019. 75 p. graf, tab.
Tese em Espanhol | LILACS | ID: biblio-1007145

RESUMO

OBJETIVO: Evaluar la Calidad de notas de Enfermería elaboradas por el personal de pediatría del Hospital Nacional Zacamil Dr. Juan José Fernández, municipio de Mejicanos, San Salvador, El Salvador, en el período de Octubre 2018 ­ febrero, 2019. DISEÑO: Estudio descriptivo de corte transversal con un universo de 54 expedientes clínicos de pacientes pediátricos hospitalizados en el servicio de pediatría del hospital nacional Zacamil Dr. Juan José Fernández., Se realizó evaluación de de 3 notas de enfermería por recurso que labora en el servicio, 18 enfermeras y auxiliares la recolección de datos, llenado y tabulado, fueron realizados por el investigador con el programa Excel en el mes de Octubre 2018 ­ febrero, 2019. RESULTADOS: Predominan el personal de 40 a más años, femenino, en su mayoría auxiliares 56%, 83% más de 10 años de laborar, destaca uso de color de tinta acorde al horario en un 100%, en relación a la firma en la nota, se destaca un 20.37% con manchones, 20% uso de firma según DUI, en un 35.19% no se registra nombre completo solamente apellido, en un 61% no están actualizados los sellos que los profesionales deben utilizar. UN 65% con uso adecuado de abreviaturas. Un 48.2% de las notas tenían tachaduras. Únicamente el 17% de las notas, contiene los signos vitales de inicio del proceso. El 100% de las notas no contienen el diagnóstico de enfermería y un 83% no de las notas no contiene registrados los procedimientos realizados. CONCLUSIONES: Socio laboralmente el personal de enfermería del Hospital Nacional Zacamil, se encuentra en edades de 40- 49 años de edad, con predominio de personal técnico, con una antigüedad laboral de más 16 años del ejercicio de la profesión de enfermería, se evidenció que el personal no cumple en su totalidad con los componentes. En relación a los niveles de calidad conforme los catorce criterios evaluados, predominó la categoría de deficientes, no reflejando los lineamientos establecidos por la Junta de Vigilancia de la Profesión de Enfermería y el Ministerio de Salud


Assuntos
Humanos , Enfermagem Pediátrica , Registros de Enfermagem , Enfermagem , Avaliação de Recursos Humanos em Saúde , Auditoria de Enfermagem , Recursos Humanos de Enfermagem no Hospital , Registros Médicos , Saúde Pública , Epidemiologia Descritiva , Estudos Transversais , Recursos Humanos de Enfermagem
16.
Int Nurs Rev ; 66(2): 191-198, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30734275

RESUMO

AIM: This study sought to review documentation of client teaching and discharge planning performed on the medical wards of an urban Jamaican hospital. BACKGROUND: Amid a chronic disease epidemic in Jamaica, adequate discharge planning and client education among hospitalized clients are essential to ensure optimal health outcomes and reduced healthcare costs. METHOD: A total of 131 records from six medical wards were audited. The audit instrument was developed based on the Ministry of Health, Jamaica guidelines, and appraised the completeness of assessment, use of the nursing process, client teaching and discharge planning. Quota sampling facilitated the selection of medical records which met the inclusion criteria. The SPSS® version 22 for Windows® facilitated data analysis. RESULTS: Eighty-eight adult (67.2%) and 43 (32.8%) paediatric records were audited; 89.3% indicated the clients were diagnosed with at least one non-communicable disease. Fourteen percent of records reflected documented evidence of client teaching within the first 72 h of admission. On the day of discharge, only 18.3% reflected client teaching. Nurses seldom began discharge planning within the first 24 h of admission as only 6.9% records had documented evidence. These trends were common to adult and paediatric units. DISCUSSION AND CONCLUSION: The requisite client teaching and discharge planning appeared to be lacking in the records reviewed and may be contributory to deficiencies noted in self-care management. Research is needed to determine factors which could facilitate improved client teaching and discharge planning in the local context. Failure to address this gap in nursing care can significantly affect the country's ability to the reduce the economic burden associated with chronic diseases. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This study highlighted an opportunity for advocacy among nurses and requires nursing leadership to collaboratively develop policies and guidelines to address discharge planning and client education among hospitalized clients. Given the significant health costs associated with non-communicable diseases this should be made a priority in the National Strategic and Action Plan for the Prevention and Control Non-communicable Diseases in Jamaica with clear articulations.


Assuntos
Registros de Enfermagem/estatística & dados numéricos , Recursos Humanos de Enfermagem no Hospital/organização & administração , Alta do Paciente/estatística & dados numéricos , Educação de Pacientes como Assunto/estatística & dados numéricos , Padrões de Prática em Enfermagem/organização & administração , Adulto , Criança , Humanos , Jamaica , Auditoria de Enfermagem
18.
Int J Nurs Stud ; 91: 101-107, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30677587

RESUMO

Introduction As the electronic health record becomes more sophisticated, commensurate advances in cost accounting have risen as a top priority for hospital leaders. This study explored: 1) the average time to complete common nursing tasks documented in the electronic health record, 2) nursing-related tasks that remain undocumented, 3) the association between observation data and actual nursing documentation, and 4) considerations for model development and report design to be used for activity based cost accounting in nursing. Methods This was an observational study completed on acute care inpatient nursing units at a large academic medical center. During a five-week period, 63 nurses from 25 units were observed for over 250 h. Results Nearly 60% of the observed nursing activities did not fit into categories readily available in, and easily abstracted from, the electronic health record. The undocumented activities accounted for over half of the observation tasks and equated to nearly 130 h, in which over 40 h were spent on the activity of documentation/charting itself. Furthermore, nearly 36 h were spent on communication, followed by 13.5 h on monitoring/surveillance, two critical tasks in nursing which cannot be overlooked. Conclusions Using the electronic health record for cost accounting in nursing is a novel approach. In addition to the electronic health record, supplementary sources of data must be included to accurately capture nursing work and associated costs. Findings and lessons learned from this study will be used to guide future work and develop a model that determines the cost of nursing care and improved value in hospitalized patients.


Assuntos
Custos e Análise de Custo , Coleta de Dados/métodos , Registros Eletrônicos de Saúde , Pacientes Internados , Recursos Humanos de Enfermagem no Hospital/economia , Humanos , Registros de Enfermagem , Estudo de Prova de Conceito , Análise e Desempenho de Tarefas , Estudos de Tempo e Movimento , Fluxo de Trabalho
19.
Hu Li Za Zhi ; 66(1): 93-100, 2019 Feb.
Artigo em Chinês | MEDLINE | ID: mdl-30648249

RESUMO

BACKGROUND & PROBLEMS: Obtaining complete electronic dialysis nursing records, a tool that facilitates communication between medical teams, is critical in terms of maintaining the continuity of nursing procedures and nursing quality. An analysis of our unit indicated that nurses lacked sufficient familiarity with electronic dialysis nursing record systems. Moreover, they received insufficient training in operating these systems and lacked the guidelines necessary to maintain these records properly. Furthermore, these systems tend to be poorly designed, and an inspection system for dialysis nursing records is currently unavailable. These factors led to a rate of record completeness of only 58.2%. PURPOSE: To raise the rate of completeness for electronic nursing records to above 90%. RESOLUTION: An intervention was conducted to accomplish seven tasks. These tasks included: modify the electronic dialysis nursing record system, input preset phrases in order to facilitate record compilation in the system, devise a manual to instruct staff on recordkeeping procedures, organize in-service training on system operations, conduct clinical scenario simulations for nurses to practice operating the system, recruit informatics nurses to teach other nurses about the operations, and implement an inspection system for these electronic records. RESULTS: After implementing the intervention, the rate of completeness for electronic nursing records improved to 96% and the average time required for nurses to complete a nursing record decreased from 21 mins 35 s to 8 mins 15 s. CONCLUSIONS: The developed intervention significantly improved the completeness of electronic nursing records, reduced the time required for recordkeeping, and ensured adequate nursing quality for dialysis patients.


Assuntos
Registros Eletrônicos de Saúde/normas , Registros de Enfermagem/normas , Diálise Renal/enfermagem , Humanos , Pesquisa em Avaliação de Enfermagem
20.
J Clin Nurs ; 28(9-10): 1719-1727, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30653788

RESUMO

AIMS AND OBJECTIVES: To describe which nursing activities are observed during the discharge of older patients with chronic diseases and to investigate the consistency between the nursing activities actually observed and those documented. BACKGROUND: The discharge from hospital of older patients with chronic diseases is a critical transition that can lead to dissatisfaction, delays in discharge, re-admission, adverse events and increased mortality. Although nurses' interventions during discharge are important for patient outcomes, little is known about the nursing activities actually performed as compared with those documented. DESIGN: An observational study of the nursing activities performed during patients' discharge and a retrospective audit of the nursing records of the same patients and nurses. METHODS: Structured nonparticipant observations were conducted of the activities performed by nurses at discharge. A retrospective audit of the nursing records relating to patient discharge, including the nursing diary and the assessment of critical issues at hospital discharge, was also conducted. The STROBE guidelines were followed (See Supporting Information Appendix S2). RESULTS: During hospital discharge of 102 patients, 1,224 nursing activities were observed. The number of activities was not related to patients' age, gender and educational level, nor to nurses' postgraduate education. Statistically significant correlations emerged between the number of activities observed and the nurses' work experience. CONCLUSIONS: A predefined discharge plan guiding nurses' activities during discharge would enable them to respond better to the care needs of elderly patients. RELEVANCE TO CLINICAL PRACTICE: Results from the study could help clinical nurses to address care priorities of patients at discharge, by using appropriate plans and checklists and improving recording rates. Novice nurses should be supported when caring for elderly patients with chronic disease at discharge.


Assuntos
Doença Crônica/enfermagem , Papel do Profissional de Enfermagem , Registros de Enfermagem , Recursos Humanos de Enfermagem no Hospital/organização & administração , Alta do Paciente/normas , Adulto , Idoso , Feminino , Humanos , Masculino , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA