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 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.

The purpose of this study was to identify the characteristics of cancer patients and the most frequently chosen nursing diagnoses, outcomes and interventions chosen for care plans from a large Midwestern acute care hospital. In addition the patients' outcome change scores and length of stay from the four oncology specialty units are investigated. Donabedian's structure-process-outcome model is the framework for this study. This is a descriptive retrospective study. The sample included a total of 2,237 patients admitted on four oncology units from June 1 to December 31, 2010. Data were retrieved from medical records, the nursing documentation system, and the tumor registry center. Demographics showed that 63% of the inpatients were female, 89% were white, 53 % were married and 26% were retired. Most patients returned home (82%); and 2% died in the hospital. Descriptive analysis identified that the most common nursing diagnoses for oncology inpatients were Acute Pain (78%), Risk for Infection (31%), and Nausea (26%). Each cancer patient had approximately 3.1 nursing diagnoses (SD=2.5), 6.3 nursing interventions (SD=5.1), and 3.7 nursing outcomes (SD=2.9). Characteristics of the patients were not found to be related to LOS (M=3.7) or outcome change scores for Pain Level among the patients with Acute Pain. Specifically, 88% of patients retained or improved outcome change scores. The most common linkage of NANDA-I, NOC, and NIC (NNN), a set of standardized nursing terminologies used in the study that represents nursing diagnoses, nursing-sensitive patient outcomes and nursing interventions, prospectively, was Acute Pain--Pain Level--Pain Management. Pain was the dominant concept in the nursing care provided to oncology patients. Risk for Infection was the most frequent nursing diagnosis in the Adult Leukemia and Bone Transplant Unit. Patients with both Acute Pain and Risk for Infection may differ among units; while the traditional study strategies rarely demonstrate this finding. Identifying the pattern of core diagnoses, interventions, and outcomes for oncology nurses can direct nursing care in clinical practice and provide direction for future research tot targets areas of high impact and guide education and evaluation of nurse competencies.

Improvement of patient care in any hospital depends primarily on the quality of nursing care. Nursing care is enhanced by the nursing process, which outlines the nursing activities to be provided for a patient. The purpose of this study was to determine to what extent the nursing process could improve the quality of nursing care, and to explore the knowledge limitations of nursing staff in implementing the nursing process, nursing care planning and proper documentation. Quantitative research, making use of an exploratory, descriptive and contextual design was conducted, utilising a structured questionnaire for data collection. Registered nurses (n=120) employed at a Referral Hospital in Tanzania served as the respondents. The findings revealed a lack of knowledge in understanding and applying the concepts of the nursing process, especially in formulating the nursing diagnosis. Recommendations pertaining to a focused in-service training programme, integrating theory and practice, were made to enhance the effective implementation of the nursing process. / Health Studies / MA (Health Studies)

Improvement of patient care in any hospital depends primarily on the quality of nursing care. Nursing care is enhanced by the nursing process, which outlines the nursing activities to be provided for a patient. The purpose of this study was to determine to what extent the nursing process could improve the quality of nursing care, and to explore the knowledge limitations of nursing staff in implementing the nursing process, nursing care planning and proper documentation. Quantitative research, making use of an exploratory, descriptive and contextual design was conducted, utilising a structured questionnaire for data collection. Registered nurses (n=120) employed at a Referral Hospital in Tanzania served as the respondents. The findings revealed a lack of knowledge in understanding and applying the concepts of the nursing process, especially in formulating the nursing diagnosis. Recommendations pertaining to a focused in-service training programme, integrating theory and practice, were made to enhance the effective implementation of the nursing process. / Health Studies / M.A. (Health Studies)

Submitted in fulfillment of the requirements of the degree of Master of Technology: Nursing, Durban University of Technology, Durban, South Africa, 2015. / Aim The aim of this study was to evaluate the use of nursing care plans in the management of patient care and to recommend guidelines for improving the quality of planned nursing care at a level 3 hospital in the Umgungundlovu district of KwaZulu-Natal. Method The case study was based on the conceptual model of care planning and employed both quantitative and qualitative research designs. The quantitative phase involved a retrospective audit of charts, using an itemised checklist to determine whether items relating to the phases of the nursing process were in evidence within the charts. The qualitative phase consisted of face-to-face interviews with registered nurses, who were asked about their understanding and use of the nursing process. Data derived were analysed using Nvivo 10 and presented as graphs, tables and written text extracts. Results The results show that the use of the standardised care plans at the study hospital had an impact on the understanding of the importance of the nursing process and the successful implementation of the care plans. Factors that had an impact on this included the registered nurses who failed to nurture the junior nurses, lack of understanding of the care plans and what was expected of the staff, staff attitudes and the heavy workload. Conclusion It was suggested that nurse leaders support the implementation and continued use of individualised care plans in order to improve critical thinking skills of nurses by implementing teaching and in-service programs, employing knowledgeable registered nurses, by developing and enforcing adherence to policies that favour care planning and nursing documentation.