Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research, Boston, Massachusetts, USA.
Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA.
Int J Nurs Knowl. 2022 Jul;33(3):234-244. doi: 10.1111/2047-3095.12372. Epub 2022 May 17.
Nurses are on the forefront of delivering care to patients hospitalized with COVID-19. Nurses' impact on patient care can be discerned through assessment and documentation strategies, including structured and unstructured narratives, clinical pathways, flowsheets, and problem-based approaches. To date, there are no published reports regarding nursing assessment and documentation during the COVID-19 pandemic using an assessment framework to capture clinical decision making, nursing diagnoses, and key social determinant of health (SDoH) data. Hence, the purpose of this investigation was to conduct an exploratory nursing documentation audit of patients hospitalized with COVID-19 during the first surge to identify types and frequency of nurse-sensitive indicators, including SDoH.
This pilot study utilized a retrospective chart review design at a single academic medical center, utilizing Gordon's Eleven Functional Health Patterns (FHP) framework to extract clinical, social, and nursing assessment data for patients hospitalized with COVID-19. Descriptive statistics were computed for continuous variables and counts/percentages for categorical variables.
Data from 94 patient records were analyzed. Most patients were male (59.6%), with a mean age of 58 years. Nearly 15% of patients were Black and 12.8% were Hispanic, most residing in four geographic areas. Nine of the 11 FHPs were reflected in nurse-sensitive indicators documented in the electronic health record. SDoH data were inconsistently documented, including race, education, history of neglect/abuse, and occupation.
The FHP framework captured many nurse-sensitive indicators during the first COVID-19 surge, although screening for and documenting SDoH data were limited.
Findings can influence the development of nursing assessment and documentation during crisis care delivery that are inclusive of distinct sociodemographic factors, in addition to clinical factors, to provide comprehensive, culturally sensitive care. Such documentation will enhance the use of nursing knowledge guided by a nursing framework to make visible the essential contributions of nurses to healthcare delivery.
护士是为 COVID-19 住院患者提供护理的第一线人员。护士对患者护理的影响可以通过评估和文档编制策略来体现，包括结构化和非结构化叙述、临床路径、流程表和基于问题的方法。迄今为止，尚无关于在 COVID-19 大流行期间使用评估框架来捕获临床决策、护理诊断和关键健康社会决定因素 (SDoH) 数据的护理评估和文档编制的报告。因此，本研究的目的是对 COVID-19 大流行期间首次激增期间住院的患者进行探索性护理文档审核，以确定护士敏感指标的类型和频率，包括 SDoH。
这项试点研究在一家学术医疗中心采用回顾性图表审查设计，利用 Gordon 的 11 个功能健康模式 (FHP) 框架提取 COVID-19 住院患者的临床、社会和护理评估数据。连续变量采用描述性统计，分类变量采用计数/百分比。
分析了 94 份患者记录的数据。大多数患者为男性（59.6%），平均年龄为 58 岁。近 15%的患者为黑人，12.8%为西班牙裔，大多数居住在四个地理区域。11 个 FHP 中有 9 个在电子健康记录中记录的护士敏感指标中得到体现。社会决定因素数据记录不一致，包括种族、教育程度、忽视/虐待史和职业。
FHP 框架在 COVID-19 首次激增期间捕获了许多护士敏感指标，尽管对 SDoH 数据的筛查和记录有限。
研究结果可以影响危机护理期间的护理评估和文档编制的发展，包括除临床因素外，还包括独特的社会人口因素，以提供全面、文化敏感的护理。这种文档编制将增强护理知识的使用，以护理框架为指导，使护士对医疗保健提供的重要贡献显而易见。
