Quality indicators of the nursing process documentation in clinical practice

Detalhes bibliográficos
Autor(a) principal: Azevedo,Oswalcir Almeida de
Data de Publicação: 2021
Outros Autores: Cruz,Diná de Almeida Lopes Monteiro da
Tipo de documento: Artigo
Idioma: eng
Título da fonte: Revista Brasileira de Enfermagem (Online)
Texto Completo: http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672021000300179
Resumo: ABSTRACT Objectives: to propose quality indicators for clinical nursing documentation Methods: methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa. Results: the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services. Conclusions: seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.
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spelling Quality indicators of the nursing process documentation in clinical practiceQuality Indicators, Health CareDocumentationNursing ProcessNursing RecordsNursing Methodology ResearchABSTRACT Objectives: to propose quality indicators for clinical nursing documentation Methods: methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa. Results: the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services. Conclusions: seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.Associação Brasileira de Enfermagem2021-01-01info:eu-repo/semantics/articleinfo:eu-repo/semantics/publishedVersiontext/htmlhttp://old.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672021000300179Revista Brasileira de Enfermagem v.74 n.3 2021reponame:Revista Brasileira de Enfermagem (Online)instname:Associação Brasileira de Enfermagem (ABEN)instacron:ABEN10.1590/0034-7167-2020-1355info:eu-repo/semantics/openAccessAzevedo,Oswalcir Almeida deCruz,Diná de Almeida Lopes Monteiro daeng2021-07-20T00:00:00Zoai:scielo:S0034-71672021000300179Revistahttp://www.scielo.br/rebenhttps://old.scielo.br/oai/scielo-oai.phpreben@abennacional.org.br||telma.garcia@abennacional.org.br|| editorreben@abennacional.org.br1984-04460034-7167opendoar:2021-07-20T00:00Revista Brasileira de Enfermagem (Online) - Associação Brasileira de Enfermagem (ABEN)false
dc.title.none.fl_str_mv Quality indicators of the nursing process documentation in clinical practice
title Quality indicators of the nursing process documentation in clinical practice
spellingShingle Quality indicators of the nursing process documentation in clinical practice
Azevedo,Oswalcir Almeida de
Quality Indicators, Health Care
Documentation
Nursing Process
Nursing Records
Nursing Methodology Research
title_short Quality indicators of the nursing process documentation in clinical practice
title_full Quality indicators of the nursing process documentation in clinical practice
title_fullStr Quality indicators of the nursing process documentation in clinical practice
title_full_unstemmed Quality indicators of the nursing process documentation in clinical practice
title_sort Quality indicators of the nursing process documentation in clinical practice
author Azevedo,Oswalcir Almeida de
author_facet Azevedo,Oswalcir Almeida de
Cruz,Diná de Almeida Lopes Monteiro da
author_role author
author2 Cruz,Diná de Almeida Lopes Monteiro da
author2_role author
dc.contributor.author.fl_str_mv Azevedo,Oswalcir Almeida de
Cruz,Diná de Almeida Lopes Monteiro da
dc.subject.por.fl_str_mv Quality Indicators, Health Care
Documentation
Nursing Process
Nursing Records
Nursing Methodology Research
topic Quality Indicators, Health Care
Documentation
Nursing Process
Nursing Records
Nursing Methodology Research
description ABSTRACT Objectives: to propose quality indicators for clinical nursing documentation Methods: methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa. Results: the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services. Conclusions: seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.
publishDate 2021
dc.date.none.fl_str_mv 2021-01-01
dc.type.driver.fl_str_mv info:eu-repo/semantics/article
dc.type.status.fl_str_mv info:eu-repo/semantics/publishedVersion
format article
status_str publishedVersion
dc.identifier.uri.fl_str_mv http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672021000300179
url http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672021000300179
dc.language.iso.fl_str_mv eng
language eng
dc.relation.none.fl_str_mv 10.1590/0034-7167-2020-1355
dc.rights.driver.fl_str_mv info:eu-repo/semantics/openAccess
eu_rights_str_mv openAccess
dc.format.none.fl_str_mv text/html
dc.publisher.none.fl_str_mv Associação Brasileira de Enfermagem
publisher.none.fl_str_mv Associação Brasileira de Enfermagem
dc.source.none.fl_str_mv Revista Brasileira de Enfermagem v.74 n.3 2021
reponame:Revista Brasileira de Enfermagem (Online)
instname:Associação Brasileira de Enfermagem (ABEN)
instacron:ABEN
instname_str Associação Brasileira de Enfermagem (ABEN)
instacron_str ABEN
institution ABEN
reponame_str Revista Brasileira de Enfermagem (Online)
collection Revista Brasileira de Enfermagem (Online)
repository.name.fl_str_mv Revista Brasileira de Enfermagem (Online) - Associação Brasileira de Enfermagem (ABEN)
repository.mail.fl_str_mv reben@abennacional.org.br||telma.garcia@abennacional.org.br|| editorreben@abennacional.org.br
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