共查询到20条相似文献,搜索用时 15 毫秒
1.
Conni DeBlieckAuthor Vitae Anne Fishman LaFlammeAuthor Vitae Mary Jane RivardAuthor Vitae Karen A. MonsenAuthor Vitae 《AORN journal》2013
Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine—Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR. 相似文献
2.
3.
4.
5.
6.
Asta Thoroddsen RN MS Margareta Ehnfors RN Dipl Nurs Ed PhD FACMI Anna Ehrenberg RN PhD 《International journal of nursing knowledge》2010,21(2):69-79
PURPOSE. To describe how nursing specialty knowledge is demonstrated in nursing records by use of standardized nursing languages. METHODS. A cross‐sectional review of nursing records (N = 265) in four specialties. FINDINGS. The most common nursing diagnoses represented basic human needs of patients across specialties. The nursing diagnoses and related interventions represented specific knowledge in each specialty. Sixty‐three nursing diagnoses (nine appeared in four specialties) and 168 nursing interventions were used (24 appeared in four specialties). CONCLUSIONS. Findings suggest that standardized nursing languages are capable of distinguishing between specialties. Further studies with large data sets are needed to explore the relationships between nursing diagnoses and nursing interventions in order to make explicit the knowledge that nurses use in their nursing practice. PRACTICE IMPLICATIONS. Nursing data in clinical practice must be stored and retrievable to support clinical decision making, advance nursing knowledge, and the unique perspective of nursing. 相似文献
7.
Morten Hertzum 《Applied clinical informatics》2021,12(1):27
Background Electronic health records (EHRs) are used in long-term care to document the patients'' condition, medication, and care, thereby supporting communication among caregivers and counteracting adverse drug events. However, the use of EHRs in long-term care has lagged behind EHR use in hospitals. In addition, most EHR research focuses on hospitals. Objective This study gives a countrywide status of the documentation-related risks to patient safety in Danish home care and nursing homes, which are the two main providers of long-term care. Such a status provides a basis for national improvement efforts and international comparisons. Method The study is based on the reports from 893 inspections of home care and nursing homes by the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed [STPS]). Results As much as 69% of the inspected institutions document inadequately to an extent that has led to demands (i.e., issues the institution is legally obliged to rectify) or requests (i.e., issues the institution is merely asked to rectify) from STPS. Documentation issues about the patients'' condition and care are present in nearly all institutions that receive demands (97%) and in the majority of those that receive requests (68%). Documentation issues about medication and consent to care are also common, but less so. The predominant risk to patient safety is incomplete documentation. It covers 72% of the documentation issues identified in the institutions that received demands; the remaining risks concern inconsistent (11%), nonexistent (7%), inaccessible (5%), and noncompliant (5%) documentation. The documentation inadequacies are similar for home care and nursing homes. Conclusion Inadequate EHR documentation is a widespread problem in Danish long-term care. While previous research mainly focuses on how EHR documentation affects patient medication, this study finds that documentation issues about the patients'' condition and care are more prevalent and that issues about their consent are also common. 相似文献
8.
《Journal of PeriAnesthesia Nursing》2021,36(4):345-350.e1
PurposeApproximately 2% of surgical patients have an existing cardiac implantable electronic device (CIED). Perioperative device reprogramming requires postoperative care to ensure that device settings are restored. Electronic health record (EHR) alerts have been shown to improve communication between providers and decrease time to necessary interventions in other areas of medicine. The aim of this quality improvement project was to create an EHR alert for postoperative CIED patients who require device reprogramming to help clinicians track, remember, and document the timely and safe restoration of device settings.DesignThis project used a pre-post observational design.MethodsThis project was conducted at a major academic medical center using a pre-post observational design. To prevent anesthesia providers from closing an encounter in the EHR before postoperative restoration of device settings, an alert was developed and embedded within the intraoperative EHR to track preoperative device reprogramming, and alert anesthesia providers to perform and document postoperative restoration of safe settings.FindingsThe postimplementation group (n = 272) had fewer unknown or undocumented preoperative CIED interventions (12.9% vs 30.9%), a 7.3% shorter device suspension time (median = 165 minutes vs 178 minutes), 6.8% improvement in documentation of postoperative re-enabling of device therapies (78.8% vs 72.0%), and a 72.48% decrease in length of stay (median = 625 hours vs 172 hours) when compared with the preimplementation group (n = 132).ConclusionElectronic prompts effectively captured patients who received preoperative CIED reprogramming and provided a process for reprogramming devices to safe settings, both significant steps in preventing negative patient outcomes associated with undocumented CIED interventions. Perioperative CIED documentation improved, and length of stay decreased after project implementation. 相似文献
9.
Suzanne Bakken William L. Holzemer Carmen J. Portillo Richard Grimes Jennifer Welch Dean Wantland 《Journal of nursing scholarship》2005,37(3):251-257
PURPOSE: To illustrate the utility of a standardized nursing terminology to calculate the dosage of the Client Adherence Profiling-Intervention Tailoring (CAP-IT) and to determine the extent to which a tailored intervention was delivered to 117 persons with HIV/AIDS who participated in the experimental arm of a randomized controlled trial (RCT). METHODS: The intervention nurse assigned nursing diagnoses from the Home Health Care Classification (HHCC) based upon CAP scores. During the IT phase of CAP-IT, the nurse delivered and documented a tailored set of nursing interventions associated with the CAP and assigned nursing diagnoses. Hierarchical linear regression was used to evaluate the extent to which the number of interventions and intervention times were tailored to client needs. RESULTS: Linear regression models that included CAP scores and nursing diagnoses as predictor variables explained 53.2% of the variance in total number of interventions and 58.9% of the variance in intervention time. CONCLUSIONS: The use of the standardized nursing terminology enabled calculation of the intervention dose and documentation that a tailored intervention was delivered. 相似文献
10.
Sheila M. Sparks DNSc RN CS 《International journal of nursing terminologies and classifications》1997,8(2):49-54
TOPIC. The use of noun phrases for nursing diagnoses instead of the current mixture of phrases and clauses
PURPOSE. This article reviews the current list of qualifiers; discusses language clarity, precision, grammatical concerns; and defines noun phrases.
SOURCE. Literature review
CONCLUSIONS. The author proposes a list of qualifiers to replace the current list, and recommends a revised list of nursing diagnoses using noun phrases to improve their clinical usefulness, allow for alphabetization, and enhance clarity. 相似文献
PURPOSE. This article reviews the current list of qualifiers; discusses language clarity, precision, grammatical concerns; and defines noun phrases.
SOURCE. Literature review
CONCLUSIONS. The author proposes a list of qualifiers to replace the current list, and recommends a revised list of nursing diagnoses using noun phrases to improve their clinical usefulness, allow for alphabetization, and enhance clarity. 相似文献
11.
《The Journal for Nurse Practitioners》2014,10(10):824-828
Nurse practitioners are being asked to implement meaningful use initiatives including electronic personal health records (PHRs), yet little research has been done on the usability of the systems from a patient perspective. This qualitative study identified patient perceptions and barriers to the use of the PHR. Four themes were identified: access issues, perceived value of the PHR, potential usability, and security issues. Specific patient issues were those around the use of technology and health literacy issues. Nurse practitioners have an opportunity to work with patients and health information technology staff to address these issues and improve patient engagement through the use of PHRs. 相似文献
12.
13.
14.
15.
Validation of the Quality of Diagnoses,Interventions, and Outcomes (Q‐DIO) Instrument for Use in Brazil and the United States
下载免费PDF全文
![点击此处可从《International journal of nursing knowledge》网站下载免费的PDF全文](/ch/ext_images/free.gif)
Graciele Fernanda da Costa Linch RN ScD Eneida Rejane Rabelo‐Silva RN ScD Gail Maria Keenan RN PhD Maria Antonieta Moraes RN ScD Janet Stifter RN Maria Müller‐Staub PhD MNS EdN RN 《International journal of nursing knowledge》2015,26(1):19-25
16.
Evan Walker Ryan McMahan Deborah Barnes Mary Katen Daniela Lamas Rebecca Sudore 《Journal of pain and symptom management》2018,55(2):256-264
Context
Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record.Objectives
The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record.Methods
Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes).Results
The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders.Conclusion
Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored. 相似文献17.
18.
19.
Marjory Gordon PhD RN FAAN Elizabeth Hiltunen MS RN CS 《International journal of nursing terminologies and classifications》1995,6(4):143-154
The purpose of this study was to identify high frequency-treatment priority nursing diagnoses in critical care nursing using survey research methods. Through a mailed survey the prevalence of 135 nursing diagnoses from the NANDA Diagnostic Taxonomy and other diagnoses was rated by a national, random sample of 678 critical care nurses. Six important diagnostic areas were: sleep-rest, activity, nutritional-metabolic, cognitive-perceptual, self-perception (mood state), and health management (risk) patterns. Twenty diagnoses were rated as nearly always or frequently present in their practice by 70% or more of the nurses. Findings can be used to focus clinical studies of the highly prevalent diagnoses. 相似文献