Quality Patient Care
Quality Patient CareIs Frequently
Measured
The Communication Systems Prevalent in
Nursing Units.
The Communication Systems Prevalent in
Nursing Units.
Through Analysis of
Accreditation Agencies Frequently Use
Accreditation Agencies Frequently Use
Nursing RecordsNursing Records
Documentationof Nursing Activities
Documentationof Nursing Activities
Objective Measures of Quality of Patient Care.
As
Proper Documentation Tools Are Essential to Help
Nurses in Better Communication
Proper Documentation Tools Are Essential to Help
Nurses in Better CommunicationAnd
HenceAnd
Hence
Refers to the Preparation and Maintenance of
Records That Describe a Patient Care.
Refers to the Preparation and Maintenance of
Records That Describe a Patient Care.
In Nursing Can Be in Form of Either
In Nursing Can Be in Form of Either
Written Oral
Documentation of Nursing CareDocumentation of Nursing Care
or
..Where As Recording
Involves
• Written documentation of the pertinent.• Written documentation of the pertinent.
• Significant aspects of all facts of daily care.• Significant aspects of all facts of daily care.
• Status of the patient’s condition throughout that time period
• Status of the patient’s condition throughout that time period
While.. Reporting
Is A Form of Oral
Documentation That Summarizes the Care
and the Patient Status
As
Both Forms of Documentation Facilitate
Continuity of Care
Both Forms of Documentation Facilitate
Continuity of Care
Allows Rapid Sharing of Patient’s Data That Assure
the Use of Current Information in Clinical
Decision Making
Allows Rapid Sharing of Patient’s Data That Assure
the Use of Current Information in Clinical
Decision Making
ReportingReporting
Provides a Permanent and Complete
Document of Patient’s Care Activities.
Provides a Permanent and Complete
Document of Patient’s Care Activities.
RecordingRecording
While
In General
It Has Been Observed That Few Nurses Give Little
Attention to Documentation Tools
It Has Been Observed That Few Nurses Give Little
Attention to Documentation Tools
The Communication System in Patient’s Units That Assess Nursing Personnel Learning
Needs for Documentation and Communication
May Help in
Identifying the Needs for Developing a Manual That
Provide Directions and Guide Lines for Nursing
Personnel
And this is to And this is to
• Upgrade Their Communication Skills• Upgrade Their Communication Skills
• Improve Documentation• Improve Documentation
• Improve Their Quality of Patient Care • Improve Their Quality of Patient Care
Assess availability of different nursing records and reports currently in use in the General Medical & Surgical units of Alexandria Main University Hospital and pattern of Documentation.
Assess nurses opinions regarding pattern of communication in such patient care units.
Assess Nurses’ Knowledge and Learning Needs for Effective Communication and Documentation System
Develop a Manual to Meet The Identified Needs
• The study was conducted at The study was conducted at the general medical and the general medical and surgical units of the Alexandria surgical units of the Alexandria Main University Hospital.Main University Hospital.
• The study was conducted at The study was conducted at the general medical and the general medical and surgical units of the Alexandria surgical units of the Alexandria Main University Hospital.Main University Hospital.
• Two general medical and two Two general medical and two general surgical units were general surgical units were randomly selected for the randomly selected for the study.study.
• Two general medical and two Two general medical and two general surgical units were general surgical units were randomly selected for the randomly selected for the study.study.• The study covered all nurses The study covered all nurses who were available in the who were available in the selected units at the time of the selected units at the time of the study.study.
• The study covered all nurses The study covered all nurses who were available in the who were available in the selected units at the time of the selected units at the time of the study.study.
• A representative sample of A representative sample of medical records of patients medical records of patients admitted at the selected units admitted at the selected units during the data collection period during the data collection period that extended over one month.that extended over one month.
• A representative sample of A representative sample of medical records of patients medical records of patients admitted at the selected units admitted at the selected units during the data collection period during the data collection period that extended over one month.that extended over one month.
•Forty medical records were Forty medical records were selected, 10 from each unit.selected, 10 from each unit.•Forty medical records were Forty medical records were selected, 10 from each unit.selected, 10 from each unit.
•The criterion for selection was The criterion for selection was that the patient had to be that the patient had to be hospitalized for at least one hospitalized for at least one week .week .
•The criterion for selection was The criterion for selection was that the patient had to be that the patient had to be hospitalized for at least one hospitalized for at least one week .week .
A) Checklist for Auditing Patient’s Record Was Developed by the Researcher Based on the Review of Current Relevant Literature
A) Checklist for Auditing Patient’s Record Was Developed by the Researcher Based on the Review of Current Relevant Literature
It is used to collect data regarding:
It is used to collect data regarding:
1. Availability of nursing records and reports used by nursing personnel in the unit.
1. Availability of nursing records and reports used by nursing personnel in the unit.
2. Pattern of documentation. A 3-point scale was used to judge the adequacy of documentation.
2. Pattern of documentation. A 3-point scale was used to judge the adequacy of documentation.
2 stands for
Adequate
2 stands for
Adequate
1 stands for
Incomplete
1 stands for
Incomplete
0 stands for No
Documentation
0 stands for No
Documentation
B) Another Checklist Was Developed to Assess Nurses’ Opinion Regarding Pattern of Communication Prevailing in Their Units.
B) Another Checklist Was Developed to Assess Nurses’ Opinion Regarding Pattern of Communication Prevailing in Their Units.
C) A Questionnaire Was Developed to Assess Nurses’ Knowledge and Learning Needs Regarding Communication Process, Principles of Proper Documentation, Recording and Reporting Methods and Their Importance and Benefits.
C) A Questionnaire Was Developed to Assess Nurses’ Knowledge and Learning Needs Regarding Communication Process, Principles of Proper Documentation, Recording and Reporting Methods and Their Importance and Benefits.A 3-point scale was used to judge the adequacy of documentation.A 3-point scale was used to judge the adequacy of documentation.
2 stands for
Adequate
2 stands for
Adequate
1 stands for
Incomplete
1 stands for
Incomplete
0 stands for No
Documentation
0 stands for No
Documentation
Based on the identified needs, a Based on the identified needs, a Manual was developed. The contents Manual was developed. The contents of the Manual were developed with of the Manual were developed with the help of current literature, taking the help of current literature, taking into consideration the educational into consideration the educational background of the nursing staff and background of the nursing staff and the general principle of adult the general principle of adult education.education.
Data Were Collected Through:
Data Were Collected Through:
1. Concurrent review of the patients’ medical records as well as reports used by nursing personnel in the selected units to assess availability of different types of nursing records and reports and pattern of documentation.
1. Concurrent review of the patients’ medical records as well as reports used by nursing personnel in the selected units to assess availability of different types of nursing records and reports and pattern of documentation.
2. Questionnaire interview with each individual nurse working at the selected units to assess the nurses’ knowledge and learning needs regarding documentation process and system.
2. Questionnaire interview with each individual nurse working at the selected units to assess the nurses’ knowledge and learning needs regarding documentation process and system.
??????
3. The Content Validity of the Developed Manual Was Assessed by a Jury of Expert Nurse Educators and Then Administered to the Head Nurses of the Selected Units.
3. The Content Validity of the Developed Manual Was Assessed by a Jury of Expert Nurse Educators and Then Administered to the Head Nurses of the Selected Units.
4. Educational Sessions Were Conducted With the Head Nurses to Clarify the Purposes of the Manual and How It Can Be Applied in Their Clinical Areas.
4. Educational Sessions Were Conducted With the Head Nurses to Clarify the Purposes of the Manual and How It Can Be Applied in Their Clinical Areas.
Availability of Nursing Records in The General Medical and Surgical
UnitsA- Records
28.57%
71.42%
AvailableNot Available
•Plan of Care Forms•Plan of Care Forms
For Example
• Medical Order • Medical Order
• Nursing Care Plan • Nursing Care Plan • Teaching Plan • Teaching Plan
• Kardex Form • Kardex Form 25%
75%
• Other Clinical Nursing Forms:• Other Clinical Nursing Forms:
For Example
• Vital Signs Record • Vital Signs Record • Fluid Balance Record • Fluid Balance Record
• Diabetes Record (Insulin Chart) • Diabetes Record (Insulin Chart)
• Coagulation Record • Coagulation Record
50%
50%
• Nursing Medication Record • Nursing Medication Record
• Narcotic Record • Narcotic Record
B- Reports
25.00%
75.00%
AvailableNot Available
Availability of Nursing Records in The General Medical and Surgical
Units
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Dar
k in
k w
ritin
g
Leg
ible
ha
ndw
ritin
g
Pat
ient
's i
dent
efi
catio
n
No
spel
ling
mis
take
s
Lan
guag
e
Usi
ng C
orr
ect
form
All
data
ent
ries
timed
&
date
d
Sta
ndrd
ize
d
obs
erv
atio
n
Cor
rect
ing
err
ors
No
dupl
icat
ion
Av
oid
bla
nk s
pace
s
Sig
ning
in f
ull n
ame
&
Pos
ition
None
Inadequate
Adequate
Adequacy of Documentation of Nursing forms at Medical Surgical Units
Adequacy of Documentation of Nursing forms at Medical Surgical Units
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Imp
ort
anc
e o
fC
om
mun
ica
tion
Ele
me
nts
of
Co
mm
unic
atio
n
Cha
nne
ls o
fC
om
mun
ica
tion
Typ
es
of
Co
mm
unic
atio
n
Co
mm
unic
atio
nB
arr
iers
Ho
w to
imp
rove
Co
mm
unic
atio
n
Co
nfe
renc
e a
s a
me
an
of c
om
m.
Learning Needs
Knowledge
Percent Distribution of Nurses’ Knowledge and Their Learning Needs Regarding
Communication Process.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
De
finiti
on
of
Re
po
rtin
g
Ba
sic
gui
de
lne
so
f re
po
rtin
g
Typ
es
of n
ursi
ngre
po
rts
Pur
po
se o
f ea
chnu
rsin
g r
ep
ort
Pro
pe
r w
ay
of
usin
g e
ach
re
po
rt
Learning Needs
Knowledge
Percent Distribution of Nurses’ Knowledge and Their Learning Needs Regarding Reporting.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
De
finiti
on
of
Re
cord
ing
Ba
sic
gui
de
lne
s o
fre
cord
ing
Nur
ses'
resp
ons
ibili
ty fo
rp
atie
nts
reco
rds
Learning Needs
Knowledge
Percent Distribution of Nurses’ Knowledge and Their Learning Needs Regarding Recording.
A. Communication with Physicians:A. Communication with Physicians:1. Physician’s Orders1. Physician’s Orders
• Physician orders are Clear• Physician orders are Clear
• Abbreviations used by physicians are known• Abbreviations used by physicians are known
• Type • Written orders• Oral orders
• Type • Written orders• Oral orders
0102030405060708090
Ph
ysic
ian
Ord
ers
are
Cle
ar
Ab
bre
via
tio
ns
us
ed
by
Ph
ysic
ian
s
are
kn
ow
n
Typ
e
Wri
tte
n/O
ral
10%
90%
Written
Oral
• Written Orders :a. in patients medical recordsb. in other forms
• Written Orders :a. in patients medical recordsb. in other forms
• Oral Orders.• Oral Orders.
A. Communication with Physicians:A. Communication with Physicians:1. Discussion of Patients Condition1. Discussion of Patients Condition
• During Daily Conference• During Daily Conference
• During Clinical Rounds• During Clinical Rounds
80%
90%
During DailyConferenceDuring Clinicalrounds
0%
10%
20%
30%
40%
50%
60%
70%
80%
Re
po
rtin
g P
atie
nts
Co
nd
itio
n o
n e
ve
rysh
ift
Wri
tte
n S
hif
tsR
ep
ort
s ar
e c
lear
Tim
e f
or
Re
po
rtin
gis
en
ou
gh
Sh
ift
Re
po
rt
B- Communication Among NursesB- Communication Among Nurses1. Shift Reports1. Shift Reports Oral
Reporting
Both
Written Reporting
Oral Reporting
Written Reporting
Both
5012
12
2. Assigning Duties2. Assigning Duties
• Person Responsible for Assigning Duties.• Person Responsible for Assigning Duties.
74%
26%
Head Nurse
Assistant head nurse
Head NurseHead Nurse
Senior Staff NurseSenior Staff Nurse
• Type of Assigning Duties• Type of Assigning Duties
80%
20%
Oral
Not Done
Oral 80%Oral 80%
Not DoneNot Done
Written 0%Written 0%
74%
26%
Special Records
Phone Calls
Special RecordsSpecial Records
Phone CallsPhone Calls
C- Interdepartmental Communication:C- Interdepartmental Communication:
Improve Nurses’ Documentation Skills
Improve Nurses’ Documentation Skills
Documentation
Manual
Documentation
Manual
Enhance Quality Patient CareEnhance Quality Patient Care
Based on the Findings of the Study, The
Following Recommendations
Would be Suggested:
Based on the Findings of the Study, The
Following Recommendations
Would be Suggested:
1The Developed Manual should be used on an ongoing basis.
The Developed Manual should be used on an ongoing basis. It should be administered to each newly employed nurse to:
• Refresh her knowledge.
• Develop an insight of her role regarding the documentation system and its importance.
It should be administered to each newly employed nurse to:
• Refresh her knowledge.
• Develop an insight of her role regarding the documentation system and its importance.
2To Help Nurses to apply the developed manual, the different forms of nursing records and reports suggested in the manual should be made available to nurses by the hospital or health authority and be kept as a permanent data source.
To Help Nurses to apply the developed manual, the different forms of nursing records and reports suggested in the manual should be made available to nurses by the hospital or health authority and be kept as a permanent data source.
3
Proper Supervision must be continuously performed by the head nurse to ensure that nurses utilize the documentation system in a proper and consistent way.
Proper Supervision must be continuously performed by the head nurse to ensure that nurses utilize the documentation system in a proper and consistent way.
4
Physicians must take into their consideration reports and records written by nurses to encourage them to use documentation of the nurses’ forms.
Physicians must take into their consideration reports and records written by nurses to encourage them to use documentation of the nurses’ forms.
5
There should be strict hospital and rules to control nurses negligence of recording and reporting.
There should be strict hospital and rules to control nurses negligence of recording and reporting.
THANKS
THANKS