Thoroddsen Asta, Ehnfors Margareta
Orebro University, Orebro, Sweden, and Faculty of Nursing, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland.
J Clin Nurs. 2007 Oct;16(10):1826-38. doi: 10.1111/j.1365-2702.2007.01836.x.
To describe the change in documentation of the nursing process in all inpatient wards in a 900-bed university hospital. Major research question was what are the differences between before and after implementation of documentation policy related to the steps of the nursing process?
Implementation of standardized languages has been shown to be difficult to accomplish in clinical practice. Patients are the source of data and their conditions, responses and well-being should be reflected in the nursing record. As such, nursing documentation can create the premises for the development of new knowledge in nursing and the improvement of nursing performance and can provide data and information necessary for nursing researchers to evaluate the quality of interventions and participate in the formulation of healthcare policy. This study is part of longitudinal project to prepare nurses for electronic documentation within the interdisciplinary health record and to improve documentation of nursing using standardized languages.
A cross-sectional study design was used: a pretest (n = 355 nursing records) for baseline status of nursing documentation, an intervention and a post-test (n = 349 nursing records) to obtain data on nursing documentation. The year-long intervention comprised planned work in groups, and educational and supporting efforts.
A statistically significant improvement was found in the use of Functional Health Patterns for documentation of nursing assessment, NANDA for nursing diagnoses and Nursing Interventions Classification for nursing interventions in documentation of daily nursing care for inpatients.
At all organizational levels intervention aimed at putting policy regarding documentation into clinical practice considerably improved daily use of standardized nursing languages. Relevance to clinical practice. Nurses need to use standardized language to document patient care data in the electronic health record and to demonstrate contributions to nursing care.
描述一家拥有900张床位的大学医院所有住院病房护理流程记录的变化。主要研究问题是与护理流程步骤相关的记录政策实施前后有哪些差异？
标准化语言在临床实践中的实施已被证明难以完成。患者是数据的来源，他们的病情、反应和健康状况应在护理记录中得到体现。因此，护理记录可为护理新知识的发展、护理绩效的提升创造前提条件，并能为护理研究人员评估干预措施质量和参与医疗保健政策制定提供必要的数据和信息。本研究是一个纵向项目的一部分，该项目旨在让护士为跨学科健康记录中的电子记录做好准备，并使用标准化语言改善护理记录。
采用横断面研究设计：进行一次预测试（n = 355份护理记录）以了解护理记录的基线状态，进行一次干预，然后进行一次后测试（n = 349份护理记录）以获取护理记录数据。为期一年的干预包括分组计划工作以及教育和支持工作。
在住院患者日常护理记录中，使用功能健康模式进行护理评估记录、使用北美护理诊断协会（NANDA）进行护理诊断记录以及使用护理干预分类法（Nursing Interventions Classification）进行护理干预记录方面，发现有统计学意义的改善。
在所有组织层面，旨在将记录政策付诸临床实践的干预措施显著改善了标准化护理语言的日常使用。与临床实践的相关性。护士需要使用标准化语言在电子健康记录中记录患者护理数据，并展示对护理工作的贡献。
