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