Adequacy of the use of nursing documentation in a PICU

Details

Serval ID
serval:BIB_A2227F63CD39
Type
Inproceedings: an article in a conference proceedings.
Publication sub-type
Poster: Summary – with images – on one page of the results of a researche project. The summaries of the poster must be entered in "Abstract" and not "Poster".
Collection
Publications
Title
Adequacy of the use of nursing documentation in a PICU
Title of the conference
29th Australian and New Zealand Annual Scientific Meeting on Intensive Care Incorporating, 10th Australian and New Zealand Paediatric and Neonatal Intensive Care Meeting
Author(s)
Cairns M., Ramelet A.S.
Address
Melbourne, Australia, October 7-10, 2004
ISBN
1036-7314
Publication state
Published
Issued date
2004
Volume
17
Series
Australian Critical Care
Pages
168
Language
english
Abstract
Accurate nursing documentation is fundamental to communication and is a legal requirement. However, nursing documentation is often identified as incomplete, inaccurate and time consuming. To facilitate nursing documentation, a newly developed critical pathway was introduced and pilot tested in the PICU in WA, in 2002. The documentation included a standardised nursing care format (seven categories) and a variance record. The
documentation was complemented by 16 nursing care guidelines of specific nursing care (e.g. care of the ventilated patient). A retrospective study was conducted, 1 year after implementation, to assess the adequacy of the use of the nursing documentation. A random review of 45 patients' charts (10%), was performed using an audit tool. The tool was developed and refined from a pilot review of five patients' charts. Results demonstrated that accuracy of nursing care format on average was 70%, but varied amongst categories. Accuracy of documentation was 93% for baseline, 80% for skin and hygiene, 76% for family needs, 65% for central nervous system, 64% for respiratory, 61% for fluid and nutrition, 50% for central venom system, and 26% for patients specific needs. Utilisation of the nursing care guidelines was correctly documented in the nursing care format in 35% of the time. Agreements between registered nurses, clinical nurses, and casual/agency nurses was good (ICC =0.87).
In summary, accuracy of nursing documentation fell below standards resulting in potential legal implications. Further education of staff, changes for clarification of the documentation, and re-evaluation are recommended.
Create date
12/03/2013 16:22
Last modification date
20/08/2019 15:08
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