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Improving nursing records with audit

Nursing Standard, 1993
This article describes the efforts of one unit to introduce an audit tool to measure the effectiveness of nursing documentation. After two years of use, the authors have been able to show that the quality of documentation is significantly better and patients have benefited from the improved communication that has resulted.
C, Roberts, R, Smith
openaire   +2 more sources

Nursing interventions in mental health and psychiatry: Content analysis of records from the nursing information systems in use in Portugal.

Journal of Psychiatric and Mental Health Nursing, 2019
INTRODUCTION The nursing intervention corresponds to a key element in the nursing process. No information was found in the literature about which major interventions are documented by nurses working in psychiatric wards. AIMS 1.
P. Gonçalves   +2 more
semanticscholar   +1 more source

NURSES' RECORDS AND HOME NURSING

JAMA: The Journal of the American Medical Association, 1927
To the Editor: —During the last few years I have noticed that an increasing number of nurses who are sent to private homes are careless about keeping records. This applies to those who are graduates of the better nursing schools as well as to those who hold diplomas from less well known institutions.
openaire   +1 more source

Adopting nursing health record standards

Informatics for Health and Social Care, 2013
The exploratory investigation described in this paper tried to identify and acknowledge the added value created by the adoption of nursing practice standards. It did so using a case study in a large Portuguese hospital. Following a literature review, five assumptions were proposed.
Álvaro, Rocha, Bruno, Rocha
openaire   +2 more sources

Implementation of Electronic Records Related to Nursing Diagnoses.

International Journal of Nursing Terminologies and Classifications, 2018
INTRODUCTION The quality of nursing care is related to the execution of the nursing process, which should be properly documented. In this context, there is an evident need to implement electronic health records with the use of standardized languages ...
Cíntia da Costa, G. Linch
semanticscholar   +1 more source

Content analysis of nursing diagnoses in mental health records in Portugal.

International Nursing Review, 2018
AIMS To identify the diagnoses documented by nurses in Portugal to describe the nursing needs within the scope of mental health nursing and the main problems in documenting these needs. BACKGROUND/INTRODUCTION The diagnosis process is an essential step
P. Gonçalves   +2 more
semanticscholar   +1 more source

[Nursing records].

Enfermeria intensiva, 1996
The good evolution of intensive care demands an intense and fluent communication. It is important for the attention to patients as well as for a better exploitation of the experience obtained day after day to have a written register of all the data, results, judgements and relevant actions which are being performed.
openaire   +1 more source

Medical Records Course for Nurses

The American Journal of Nursing, 1950
M ANY nursing students probably feel that the hospital medical record librarian is a fussy individual who is overly concerned with filling out blank spaces on a printed form and insisting that they do the same. Fussy? Perhaps. Overly concerned? No! Time after time the life of a patient, the professional standing and financial well-being of a doctor ...
openaire   +2 more sources

Audio recording nurse-patient interactions

Nursing Standard, 2003
Clinical supervision is accepted as important in all areas of nursing. There are various methods available for conducting clinical supervision but the most commonly used is self-reporting by the supervisee to his or her supervisor. However, other methods might also be applicable.This article discusses the merits of using audio recordings of nurse ...
openaire   +2 more sources

Quality of Electronic Nursing Records: The Impact of Educational Interventions During a Hospital Accreditation Process

Computers, Informatics, Nursing, 2017
Aline Tsuma Gaedke Nomura   +4 more
semanticscholar   +1 more source

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