|
[article] | Titre : |
Accuracy of documentation in the nursing care plan in long-term institutional care |
| Type de document : |
Article |
| Auteurs : |
Astrid Tuinman ; Mathieu H.G. de Greef ; Wim P. Krijnen ; [et al.] |
| Année de publication : |
2017 |
| Article en page(s) : |
p. 578-583 |
| Langues : |
Anglais (eng) |
| Descripteurs : |
HE Vinci
Démarche de soins infirmiers ; Documentation ; Maisons de repos ; Personne âgée ; Plan de soins
|
| Mots-clés : |
Soins de longue durée documentation en santé Étude transversale |
| Résumé : |
Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation. |
| Disponible en ligne : |
Non |
in Geriatric Nursing > Vol. 38, n°6 (November/December 2017) . - p. 578-583
[article] Accuracy of documentation in the nursing care plan in long-term institutional care [Article] / Astrid Tuinman ; Mathieu H.G. de Greef ; Wim P. Krijnen ; [et al.] . - 2017 . - p. 578-583. Langues : Anglais ( eng) in Geriatric Nursing > Vol. 38, n°6 (November/December 2017) . - p. 578-583 | Descripteurs : |
HE Vinci
Démarche de soins infirmiers ; Documentation ; Maisons de repos ; Personne âgée ; Plan de soins
|
| Mots-clés : |
Soins de longue durée documentation en santé Étude transversale |
| Résumé : |
Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation. |
| Disponible en ligne : |
Non |
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