Adequacy of the use of nursing documentation in a PICU

Détails

ID Serval
serval:BIB_A2227F63CD39
Type
Actes de conférence (partie): contribution originale à la littérature scientifique, publiée à l'occasion de conférences scientifiques, dans un ouvrage de compte-rendu (proceedings), ou dans l'édition spéciale d'un journal reconnu (conference proceedings).
Sous-type
Poster: résume de manière illustrée et sur une page unique les résultats d'un projet de recherche. Les résumés de poster doivent être entrés sous "Abstract" et non "Poster".
Collection
Publications
Titre
Adequacy of the use of nursing documentation in a PICU
Titre de la conférence
29th Australian and New Zealand Annual Scientific Meeting on Intensive Care Incorporating, 10th Australian and New Zealand Paediatric and Neonatal Intensive Care Meeting
Auteur(s)
Cairns M., Ramelet A.S.
Adresse
Melbourne, Australia, October 7-10, 2004
ISBN
1036-7314
Statut éditorial
Publié
Date de publication
2004
Volume
17
Série
Australian Critical Care
Pages
168
Langue
anglais
Résumé
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.
Création de la notice
12/03/2013 17:22
Dernière modification de la notice
20/08/2019 16:08
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