Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses' level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses' documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses' documentation practices and that a tailored EHR may improve documentation practices.
Download full-text PDF |
Source |
|---|---|
| http://dx.doi.org/10.1016/j.aorn.2017.05.003 | DOI Listing |
Publication Analysis
Top Keywords
Similar Publications
Natural Language Processing Identifies Under-Documentation of Symptoms in Patients on Hemodialysis.
Kidney360
January 2025
The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, US.
Background: Patients on hemodialysis (HD) have a high burden of emotional and physical symptoms. These symptoms are often under-recognized. NLP can be used to identify patient symptoms from the EHR.
View Article and Find Full Text PDFCharacteristics and outcomes of communities of practice in allied health educators: rapid review.
J Interprof Care
January 2025
University of South Australia Allied Health and Human Performance, South Australia, Australia.
Allied health clinical educators (AHCEs) are vital to health professional student education and clinical education is often expected in a job role. Communities of practice (CoPs) may be a strategy to meet educator learning needs. A rapid review was conducted to determine the structures, purposes, and outcomes of AHCE CoPs, and barriers or enablers of participation in CoPs.
View Article and Find Full Text PDFAccuracy of nursing diagnoses identified at admission and discharge of patients with decompensated heart failure.
Int J Nurs Knowl
January 2025
Paulista Nursing School, Federal University of São Paulo, São Paulo, São Paulo, Brasil.
Purpose: To determine the accuracy of nursing diagnoses at hospital admission and discharge for patients with heart failure (HF).
Methods: This comparative study examined the documentation in 155 medical records of patients with an admitting diagnosis of HF during August 2018 and July 2019. An audit tool was used to record the diagnoses made by nurses during routine care at the time of admission and discharge.
Instance maps as an organising concept for complex experimental workflows as demonstrated for (nano)material safety research.
Beilstein J Nanotechnol
January 2025
Seven Past Nine GmbH, Rebacker 68, 79650 Schopfheim, Germany.
Nanosafety assessment, which seeks to evaluate the risks from exposure to nanoscale materials, spans materials synthesis and characterisation, exposure science, toxicology, and computational approaches, resulting in complex experimental workflows and diverse data types. Managing the data flows, with a focus on provenance (who generated the data and for what purpose) and quality (how was the data generated, using which protocol with which controls), as part of good research output management, is necessary to maximise the reuse potential and value of the data. Instance maps have been developed and evolved to visualise experimental nanosafety workflows and to bridge the gap between the theoretical principles of FAIR (Findable, Accessible, Interoperable and Re-usable) data and the everyday practice of experimental researchers.
View Article and Find Full Text PDFWhy the Delay? A Quality Improvement Initiative for Delayed Cord Clamping in Preterm Infants.
J Paediatr Child Health
January 2025
Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.
Aim: To improve delayed cord clamping (DCC) rates for preterm infants (≤ 34 + 0 weeks' gestation) and establish DCC as standard practice using quality improvement (QI) methods.
Methods: A multi-departmental initiative was undertaken. An audit of DCC for preterm infants born at or before 34 + 0 weeks was performed.
Want AI Summaries of new PubMed Abstracts delivered to your In-box?
Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!