A emergência psiquiátrica é uma unidade complexa devido à demanda de pacientes com várias patologias psiquiátricas e clínicas associadas e distintas, com alta rotatividade. O objetivo deste trabalho foi analisar a percepção da equipe de enfermagem quanto à Sistematização da Assistência de Enfermagem em um serviço de emergência psiquiátrica, enfatizando os aspectos relacionados à sua implementação. O estudo foi desenvolvido utilizando o método qualitativa e a coleta de dados se deu através de entrevistas e grupo focal com os diferentes profissionais envolvidos no cuidado de enfermagem da Unidade de Emergência do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. Os resultados apontaram que a equipe percebe as contribuições da Sistematização da Assistência de Enfermagem (SAE) para o trabalho da equipe de enfermagem, no entanto uma série de dificuldades em relação à consolidação da Sistematização da Assistência de Enfermagem nesta unidade foram apontados, bem como propostas de melhorias e elementos essenciais que contribuiriam para a efetiva implementação da SAE na referida Unidade. Adequações nos instrumentos, treinamentos mais focados e estratégias participativas são descritos como elementos-chave para este processo / Psychiatric emergency is a complex unit due to the demand of patients with various psychiatric and medical conditions associated and distinct, with high turnover. The objective of this study was to analyze the perception of the nursing team about the systematization of nursing care in a psychiatric emergency service, emphasizing the aspects related to its implementation. The study was conducted using qualitative method and the data collection was carried out through interviews and focus groups with the different professionals involved in nursing care of the Emergency Unit of the Hospital of the Ribeirão Preto Medical School. The results showed that the team realizes the contributions of the Systematization Of Nursing Assistance (SNA) for the work of the nursing staff, however a number of difficulties in relation to the consolidation of systematization of nursing care in this unit were appointed and proposals improvements and essential elements that contribute to the effective implementation of SNA in that unit. Adjustments in the instruments, more focused training and participatory strategies are described as key elements to this process

Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the quality of documentation of patient care in nurses' notes in a home health agency in central Texas. A retrospective audit of quality of nursing documentation using the Nurse and Midwifery Content Audit Tool (NMCAT) was done. A pre- and posttest design was used. A convenience sample of de-identified nurses' notes (80 pre- and 80 post) was selected from active patient records in the agency (n = 160). Descriptive and inferential statistics from the project showed that there was improved quality for the 15 criteria representing quality nursing documentation. After the educational intervention, documentation of patient's status if changed or unchanged improved to 80%, and patient's response to treatment improved (57% to 85%), entries were written as incidents occurred improved (53% to 64%). The nurse refers to the patient by name improved (0% to 66%). These findings were an indication of practice change, validating the need for periodic audits of nurses' notes in the agency in order to demonstrate compliance with quality standards. Based on the project findings, a retraining program is recommended to improve structured nursing documentation in a home health agency. This project is likely to contribute to social change as it enhanced the information communicated to other health care providers, coordination of care, and patient outcomes.

<p>The purpose of this thesis was to study different aspects of nursing content in patient records with special reference to nursing home care. The thesis focused on the content, comprehensiveness, accuracy and auditing of records, as well as the practice and perceptions of nurses in relation to recording. A national sample of nurses was asked to complete a questionnaire. The effects on recording and nurses' practice and perceptions in nursing homes following educational intervention were studied. Accuracy was examined through record reviews and interviews with nurses and patients. A literature review of record auditing methods was performed and findings from this search were applied in the assessment of a set of records.</p><p> The results indicate that the VIPS model, as a structure for nursing recording, is widespread and shows validity across various areas in Swedish health care. After the educational intervention program, documentation in nursing home care improved significantly in the study group concerning notes on nursing history, nursing status, nursing diagnoses, interventions and discharge notes. Systematic and comprehensive assessment grounded in research-based criteria were not used in the records. Accuracy varied considerably and was significantly better for some areas in the study group. After intervention, the nurses in the study group indicated that they recorded assessments of patients with greater frequency, showed greater satisfaction with their documentation and spent less time on oral reports. Procedures in auditing patient records were found to encompass four approaches: formal structure, process comprehensiveness, knowledge based and accuracy. </p><p> In conclusion, the evidence suggests that there are serious flaws in the nursing content of nursing home records though improvements can be achieved through educational means. Presently, there are serious limitations in using the patient record as the sole source of data for care delivery, quality assessment and evaluation of care.</p>

The purpose of this thesis was to study different aspects of nursing content in patient records with special reference to nursing home care. The thesis focused on the content, comprehensiveness, accuracy and auditing of records, as well as the practice and perceptions of nurses in relation to recording. A national sample of nurses was asked to complete a questionnaire. The effects on recording and nurses' practice and perceptions in nursing homes following educational intervention were studied. Accuracy was examined through record reviews and interviews with nurses and patients. A literature review of record auditing methods was performed and findings from this search were applied in the assessment of a set of records. The results indicate that the VIPS model, as a structure for nursing recording, is widespread and shows validity across various areas in Swedish health care. After the educational intervention program, documentation in nursing home care improved significantly in the study group concerning notes on nursing history, nursing status, nursing diagnoses, interventions and discharge notes. Systematic and comprehensive assessment grounded in research-based criteria were not used in the records. Accuracy varied considerably and was significantly better for some areas in the study group. After intervention, the nurses in the study group indicated that they recorded assessments of patients with greater frequency, showed greater satisfaction with their documentation and spent less time on oral reports. Procedures in auditing patient records were found to encompass four approaches: formal structure, process comprehensiveness, knowledge based and accuracy. In conclusion, the evidence suggests that there are serious flaws in the nursing content of nursing home records though improvements can be achieved through educational means. Presently, there are serious limitations in using the patient record as the sole source of data for care delivery, quality assessment and evaluation of care.

With the advances in technology, the change of the healthcare environment, and the need for users, the use of computerized support systems or expert systems are able to cut down costs for unnecessary procedures, achieve higher levels of efficiency and productivity. Applied to the nursing department, it may provide good quality of care, decrease the time that nurses duplicate patient history, reduce nurses¡¦ burden and enhance the abilities to solve problems. The topic of this research mainly focused on the nursing department in the pediatric ward. I propose a framework for nursing knowledge management by using subjective data, objective data, assessment, and care plan (SOAP), which is used by the nursing staffs as a way of decision-making processes. The method is to collect subjective and objective data, read relevant clinical practice guidelines, make clinical judgments about patients¡¦ actual or potential problems and provide applicable nursing plans and interventions. The staffs review and make final decision to accept or reject these judgments, nursing plans and related interventions. If the staffs reject any judgment, nursing plan and intervention, the system should have inquiry-signs to ask physician and nursing staff. Then the staffs correct the inappropriateness. These clear and easy-to-follow processes help student nurses or beginning nurses cultivate their abilities to care and hope it can provide as a guide to nursing teaching and clinical patient care.

SAMMANFATTNING Att arbeta i svensk hälso- och sjukvård idag innebär att arbeta i en balans mellan stressiga och stimulerande arbetssituationer. I sjuksköterskors arbetsuppgifter ingår det, utöver de arbetsuppgifter som utförs inom ens verksamhet, att handleda sjuksköterskestudenter. Tidigare studier visar på att handledning kräver mycket tid och energi och kan leda till stress hos personalen. Samtidigt kan handledning vara väldigt givande för personalen då man ser studenten växa i sin yrkesroll och att handledare i och med det kan växa i sin egen yrkesroll som sjuksköterska. Omvårdnadsprocessen är en central del i sjuksköterskestudenters utbildning och framförallt i verksamhetsförlagd utbildning i termin tre under sjuksköterskeutbildningen. På en akutvårdsavdelning kan patienter som har kort förväntad vårdtid eller patienter som är i behov av extra övervakning eller kontroller vårdas. Tidigare studier som genomförts på sjuksköterskor som är verksamma inom akutsjukvård visar att handledning kräver mycket tid och energi av de som handleder. Syftet med studien var att belysa sjuksköterskors upplevelse av att handleda sjuksköterskestudenter i omvårdnadsprocessen på en akutvårdsavdelning. Metoden som användes var en kvalitativ intervjustudie där semistrukturerade intervjuer genomfördes med sju respondenter från ett sjukhus i Stockholmsområdet. Intervjuerna analyserades med hjälp av kvalitativ innehållsanalys. Analysen resulterade i fem kategorier med tillhörande underkategorier. Ur dessa kategorier kunde författaren fastställa tre teman som var Förhållningssätt, Begränsningar och Möjligheter. Resultatet visade att upplevelsen av att handleda sjuksköterskestudenter i omvårdnadsprocessen på en akutvårdsavdelning kan skilja sig från handledare till handledare. Oavsett vilken vana sjuksköterskor har i rollen som handledare eller vilka strategier de skapar sig i sin handledarroll så finns det strukturella faktorer på en akutvårdsavdelning som påverkar lärandet för studenten. Det kan vara en bra miljö att möta redan tidigt under utbildningen men gentemot de lärandemål i termin tre där omvårdnadsprocessen står i centrum så upplevs akutvårdsavdelning inte som en optimal lärandemiljö. Sjuksköterskor kan trots detta uppleva att handledningen i sig kan leda till professionell utveckling i den egna yrkesrollen då handledare lär sig själv genom att lära andra. Slutsatsen är att handledande sjuksköterskor upplever att en akutvårdsavdelning inte är en optimal miljö för handledning i omvårdnadsprocessen. För att framöver kunna ta emot studenter i termin tre så finns det ett behov av att lärandemiljön anpassas mer efter studenterna och de som handleder snarare än att studenterna ska anpassa sig efter verksamheten. Det finns ett värde i att skapa en välfungerande lärandemiljö för studenten då det även leder till en professionell utveckling hos de som handleder samt en god omvårdnad för patienterna.

SAMMANFATTNING Syfte: Syftet med detta arbete var att undersöka sjuksköterskors uppfattning om omvårdnadsdokumentation och dess påverkan på omvårdnadsarbetet. Metod: Kvalitativ intervjustudie med innehållsanalys enligt Lundman och Hällgren Graneheim (2008). Bekvämlighetsurval med fem sjuksköterskor från olika avdelningar på ett Universitetssjukhus i Mellansverige. Resultat: Sjuksköterskor i denna studie uppfattade att dokumentationen tar tid, det är mycket som ska dokumenteras och att kvalitén varierade. De uppfattade också att information kunde gå förlorad på grund av att många skrev på flera olika ställen. Dokumentationen upplevdes ibland som inkonsekvent eftersom sjuksköterskorna inte dokumenterade exakt lika. De belyste också att systemet var rörigt och ologiskt. Dokumentationen upplevdes ge vägledning. Det är viktigt att samarbeta mellan olika professioner samt att dokumentationen följs upp av den som tar efter. Sjuksköterskorna prioriterade det medicinska framför omvårdnaden och arbetsbördan gjorde det svårt att hinna dokumentera. Dokumentationen synliggjorde omvårdnaden samt att den kunde användas för att utvärdera vården. Slutsats: Sjuksköterskor uppfattade dokumentation som problematisk och tidsödande. Samtidigt tyckte de att det fanns vinster med dokumentation då det gav patientsäkerhet och kunde användas för att utvärdera vården. Mer arbete behövs för att nå konsensus i hur dokumentation på avdelning skall se ut. Det behövs mer forskning kring hur dokumentation påverkar omvårdnadsarbetet. / ABSTRACT Aim: The aim of this study was to investigate nurses’ perception of nursing documentation and its impact on nursing. Method: Qualitative interview study with content analysis according to Lundman and Hällgren Graneheim (2008). Convenience sample of five nurses from different wards of a University hospital in central Sweden. Result: Nurses in this study perceived the documentation as time consuming, there is a lot to be documented and that the quality varied. They also observed that the information could be lost due to many writing in several different places. The documentation is sometimes perceived as inconsistent because nurses did not document exactly alike. They also highlighted that the system was messy and illogical. Documentation was perceived as giving guidance. It is important to cooperate between different professions and that the documentation is followed up by the next person. The nurses prioritized the medical instead of nursing care and workload made ​​it difficult to find time to document. Documentation made​​ nursing care visible and it could be used to evaluate healthcare. Conclusion: Nurses perceived documentation as problematic and time consuming. They also thought there were gains of documentation when it gave patient safety and could be used to evaluate care. More work is needed to reach consensus in the documentation should be carried out. More research is required on how documentation affects nursing.

Thesis (M.H.A.)--University of Michigan, 1967.

Thesis (M.S.)--University of Michigan, 1995.

Thesis (M.H.A.)--University of Michigan, 1967.