Documentation in Psychiatric Nursing

Assessment of quality in psychiatric nursing documentation – a clinical audit

BACKGROUND Quality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of thi...

Psychiatric Nursing

Computer-based nursing documentation in nursing homes: A feasibility study.

The burden of paper-based nursing documentation has led to increasing complaints and decreasing job satisfaction amongst aged-care workers in Australian nursing homes. The automation of nursing documentation has been identified as one of the possible strategies to address this issue. A major obstacle to the introduction of IT solutions, however, has been a prevailing doubt concerning the abilit...

Nursing Outcome Documentation in Nursing Notes of Cardiac-Surgery Patients

This study analyzed what nurses wrote in narrative nursing notes for nursing outcome of cardiac-surgery patients. The nursing notes of 46 patients were decomposed into phrases and analyzed based on the nursing process. Eight patterns were extracted according to different combinations of nursing-process components, of which 29.2% have nursing outcome phrases. The content of the nursing notes was...

Nursing Care and Documentation Assistant with an Electronic Nursing Management System in Neonatal Intensive Care Unit

Background: All nursing cares require decision-making, and the ability to make the best decisions impact upon the quality of nursing care. Moreover, authenticity and accuracy of the best cares may be questioned if not recorded and reported properly and in a standard manner. We aimed to design and implement an electronic nursing managementsystem and then evaluate satisfaction of nurses with the ...