Abstract:
INTRODUCTION:The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated. PURPOSE:To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans. METHODS:A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study. RESULTS:There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes. CONCLUSIONS:The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes.
journal_name
Int J Med Informjournal_title
International journal of medical informaticsauthors
Wang N,Yu P,Hailey Ddoi
10.1016/j.ijmedinf.2015.04.004subject
Has Abstractpub_date
2015-08-01 00:00:00pages
561-9issue
8eissn
1386-5056issn
1872-8243pii
S1386-5056(15)00091-Xjournal_volume
84pub_type
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pub_type: 杂志文章
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journal_title:International journal of medical informatics
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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journal_title:International journal of medical informatics
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journal_title:International journal of medical informatics
pub_type: 杂志文章,多中心研究
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journal_title:International journal of medical informatics
pub_type: 杂志文章
doi:10.1016/j.ijmedinf.2004.08.004
更新日期:2004-11-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2013-04-01 00:00:00
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journal_title:International journal of medical informatics
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2020-09-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2020-09-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2013-02-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2015-10-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
doi:10.1016/j.ijmedinf.2012.11.007
更新日期:2013-04-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2020-06-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2013-08-01 00:00:00
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journal_title:International journal of medical informatics
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更新日期:2016-12-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2010-01-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2006-01-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2007-10-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2008-11-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
doi:10.1016/j.ijmedinf.2016.07.005
更新日期:2016-10-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
doi:10.1016/j.ijmedinf.2014.06.007
更新日期:2014-09-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2014-05-01 00:00:00
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journal_title:International journal of medical informatics
pub_type: 杂志文章
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更新日期:2013-06-01 00:00:00