Quality criteria, instruments, and requirements for nursing documentation

Autor: Wolter Paans, Kim de Groot, Anneke L. Francke, M. Triemstra
Jazyk: angličtina
Rok vydání: 2019
Předmět:
Zdroj: Journal of Advanced Nursing. 75(7):1379-1393
ISSN: 0309-2402
Popis: To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation.Systematic review of systematic reviews.We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches.Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis.Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff.Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation.There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.目的: 了解护理文件质量标准、编制工具和要求方面现有循证概况 设计: 对系统评价进行系统综述 数据来源: 我们系统地搜索了文献数据库和护理学数据库,搜索范围从2007年至2017年8月。我们还进行了其他搜索 综述方法: 两位研究人员各自分步综述、评估所选综述方法的质量以及使用预定义的提取格式提取数据。我们进行了描述性综合分析。 结果: 包括11项系统评价,从遵循护理程序和使用标准化的护理术语的重要性方面讲述几个质量标准。此外,还叙述了一些用于评估文件质量的循证工具如DCatch。而且发现电子护理文件的格式和系统的几个要求涉及到用户友好与护理人员协商发展的重要性。 结论: 使文件与护理程序保持一致、使用标准术语、采用用户友好的格式和系统,这些对于建立高质量护理文件似乎非常重要。建立高质量文件的一大挑战即为缺乏循证的质量指标。 影响: 在护理实践中,无法确定为建立高质量文件必须要满足哪些标准。 使文件与护理程序保持一致、使用标准术语、采用用户友好的格式和系统似乎很重要。 这些发现可以帮助护理人员和保健组织提高护理文件编制质量。.
Databáze: OpenAIRE
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