Quality indicators of the nursing process documentation in clinical practice
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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Associação Brasileira de Enfermagem
2021
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oai:scielo:S0034-716720210003001792021-07-20Quality indicators of the nursing process documentation in clinical practiceAzevedo,Oswalcir Almeida deCruz,Diná de Almeida Lopes Monteiro da Quality Indicators, Health Care Documentation Nursing Process Nursing Records Nursing Methodology Research 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.info:eu-repo/semantics/openAccessAssociação Brasileira de EnfermagemRevista Brasileira de Enfermagem v.74 n.3 20212021-01-01info:eu-repo/semantics/articletext/htmlhttp://old.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672021000300179en10.1590/0034-7167-2020-1355 |
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Azevedo,Oswalcir Almeida de Cruz,Diná de Almeida Lopes Monteiro da |
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Azevedo,Oswalcir Almeida de Cruz,Diná de Almeida Lopes Monteiro da Quality indicators of the nursing process documentation in clinical practice |
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Azevedo,Oswalcir Almeida de Cruz,Diná de Almeida Lopes Monteiro da |
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Azevedo,Oswalcir Almeida de |
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Quality indicators of the nursing process documentation in clinical practice |
| title_short |
Quality indicators of the nursing process documentation in clinical practice |
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Quality indicators of the nursing process documentation in clinical practice |
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Quality indicators of the nursing process documentation in clinical practice |
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Quality indicators of the nursing process documentation in clinical practice |
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quality indicators of the nursing process documentation in clinical practice |
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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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Associação Brasileira de Enfermagem |
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2021 |
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http://old.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672021000300179 |
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AT azevedooswalciralmeidade qualityindicatorsofthenursingprocessdocumentationinclinicalpractice AT cruzdinadealmeidalopesmonteiroda qualityindicatorsofthenursingprocessdocumentationinclinicalpractice |
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