{"title":"The Accuracy of Documented Nursing Care Plan among Registered Nurses","authors":"Muneerah Mahmood Alhawsawi","doi":"10.15520/IJMHS.V11I05.3301","DOIUrl":null,"url":null,"abstract":"Background: Nursing documentation is a record of care planned and provided by qualified nurses under the guidance of a competent nurse for each patient as well as the clients. \nObjective: to provide published studies about accuracy of nursing documentation. \nMethods: Searches were conducted using the following electronic databases: PUBMED, MEDLIN, CINAHAL, SAUDI DIGETAL LIBRALY and GOOGLE SCOLAR as gray data base. Search was limited to English-Language publication. And include study over 10year period. \nResult: nursing documentations is inaccurate, lacking precision, and low in quality. Factors that influence nursing documentation differ but are also interrelated with each other. Shortage of employees, insufficient knowledge about the significance of documentation, patient load, lack of hospital education, and lack of support from nurse leaders are the reported challenges to documentation. \nConclusion: Most of the lecture revel the necessary need of nursing documentation practice. Affected factor and with several recommendations for improvement noted. \nKeywords: ''nursing care plan,\" \"nursing documentation,'' \"accuracy of documentation\" and ''nursing report.'' \n ","PeriodicalId":13590,"journal":{"name":"Innovative Journal of Medical and Health Science","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2021-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Innovative Journal of Medical and Health Science","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.15520/IJMHS.V11I05.3301","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
引用次数: 0
Abstract
Background: Nursing documentation is a record of care planned and provided by qualified nurses under the guidance of a competent nurse for each patient as well as the clients.
Objective: to provide published studies about accuracy of nursing documentation.
Methods: Searches were conducted using the following electronic databases: PUBMED, MEDLIN, CINAHAL, SAUDI DIGETAL LIBRALY and GOOGLE SCOLAR as gray data base. Search was limited to English-Language publication. And include study over 10year period.
Result: nursing documentations is inaccurate, lacking precision, and low in quality. Factors that influence nursing documentation differ but are also interrelated with each other. Shortage of employees, insufficient knowledge about the significance of documentation, patient load, lack of hospital education, and lack of support from nurse leaders are the reported challenges to documentation.
Conclusion: Most of the lecture revel the necessary need of nursing documentation practice. Affected factor and with several recommendations for improvement noted.
Keywords: ''nursing care plan," "nursing documentation,'' "accuracy of documentation" and ''nursing report.''
背景:护理文件是由合格护士在称职护士的指导下为每位患者和客户计划和提供的护理记录。目的:提供有关护理文献准确性的已发表研究。方法:利用PUBMED、MEDLIN、CINAHAL、SAUDI digital library和谷歌SCOLAR等电子数据库作为灰色数据库进行检索。搜索仅限于英文出版物。包括超过10年的研究。结果:护理文献不准确,缺乏准确性,质量不高。影响护理文献的因素不同,但也相互关联。员工短缺、对文件的重要性认识不足、患者负荷、缺乏医院教育以及缺乏护士领导的支持是报告中对文件的挑战。结论:大部分讲座都揭示了护理文献实践的必要性。影响因素,并提出若干改进建议。关键词:“护理计划”、“护理文件”、“文件准确性”、“护理报告”。