Nursing documentation: Frameworks and barriers

References

• Armon, K., MacFaul, R., Werneke, U., & Stephenson, T. (2004). The impact of presenting problem based guidelines for children with medical problems in an accident and emergency department. Archives of Disease in Childhood, 89, 159–164.
   Google Scholar
• Ball, D., & Murphy, B. (2008). Taking SOAP notes: Clean up your client documentation using a system favoured by the medical community. IDEA Fitness Journal, 5(4), 32–35.
   Google Scholar
• Banner, L., & Olney, C. M. (2009). Automated clinical documentation. Computers, Informatics, Nursing, 27(2), 75–81.
   Google Scholar
• Bjorvell, C., Wredling, R., & Thorell-Ekstrand, I. (2003). Improving documentation using a nursing model. Journal of Advanced Nursing, 43(4), 402–410.
   Google Scholar
• Bosman, R. J., Rood, E., Oudemans-van Stratten, H. M., Van der Spoel, J. I., Wester, J. P. J., & Zandstra, D. F. (2003). Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery. Intensive Care Medicine, 29, 83–90.
   Google Scholar
• Burgum, M. (1996). A new path to documentation. Australian Nursing Journal, 3(7), 38–40.
   Google Scholar
• College of Nurses Ontario [CNO]. (2005). Practice standard: Documentation. Toronto, ON, Canada: Author.
   Google Scholar
• College of Registered Nurses of British Columbia [CRNBC]. (n.d.). Practice support: Nursing documentation. Vancouver, BC, Canada: Author.
   Google Scholar
• Darmer, M. R., Ankerson, L., Neilsen, B. G., Landberger, G., Lippert, E., & Egerod, I. (2006). Nursing documentation audit – The effect of a VIPS implementation programme in Denmark. Journal of Clinical Nursing, 15, 525–534.
   Google Scholar
• Daskein, R., Moyle, W., & Creedy, D. (2009). Aged-care nurse’s knowledge of nursing documentation: An Australian perspective. Journal of Clinical Nursing, 18(14), 2087–2095.
   Google Scholar
• Delaune, M. F., & Bemis-Dougherty, A. (2007, February). Documentation in physical therapy services. Physical Therapy Magazine, pp. 82–84.
   Google Scholar
• Dimond, B. (2005a). Abbreviations: The need for legibility and accuracy in documentation. British Journal of Nursing, 14(12), 665–666.
   Google Scholar
• Dimond, B. (2005b). Prescription and medication records. British Journal of Nursing, 14(22), 1203–1205.
   Google Scholar
• Dion, X. (2001). Record keeping and nurse prescribing: An area of concern. British Journal of Community Nursing, 6(4), 193–198.
   Google Scholar
• Donnelly, W. J. (2005). Patient centered care require a patient centered medical record. Academic Medicine, 80(1), 33–38.
   Google Scholar
• Ehrenberg, A., & Birgersson, C. (2003). Nursing documentation of leg ulcers: Adherence to clinical guidelines in a Swedish primary health care district. Scandinavian Journal of Caring Sciences, 17, 278–284.
   Google Scholar
• Ehrenberg, A., Ehnfors, M., & Thorell-Ekstrand, I. (1996). Nursing documentation in patient records: Experience of the use of the VIPS model. Journal of Advanced Nursing, 24, 853–867.
   Google Scholar
• Gagan, M. J. (2009). The SOAP format enhances communication. Kai Tiaki New Zealand, 15(5), 15.
   Google Scholar
• Gjevjon, E. R., & Hellesø, R. (2010).The quality of home care nurses documentation in new electronic patient records. Journal of Clinical Nursing, 19(1–2), 100–108.
   Google Scholar
• Griffith, R. (2004). Putting the record straight: The importance of documentation. British Journal of Community Nursing, 9(3), 122–125.
   Google Scholar
• Grooper, E. I., & Dicapo, R. (1995). The P.A.R.T. system: Perfecting actual recording talent. Nursing Management, 26(4), 46–48.
   Google Scholar
• Gugerty, B., Maranda, M. J., Beachley, M., Navarro, V. B., Newbold, S., Hawk, W., et al. (2007). Challenges and opportunities in documentation of the nursing care of patients: A report of the Maryland nursing workforce commission, documentation work group. Baltimore, MD: Maryland Nursing Workforce Commission.
   Google Scholar
• Hager, L., & Munden, J. (Eds.). (2008). Complete guide to documentation (2nd ed.). Ambler, PA: Lippincott Williams and Wilkins.
   Google Scholar
• Hamilton, D. (1992). S.O.A.P. notes now a requirement, not an option. Chiropractic Journal, 7(3), 19.
   Google Scholar
• Häyrinen, K., & Saranto, K. (2009). The use of nursing terminology in electronic documentation. In K. Saranto, P. F. Brennan, H. Park, M. Tallberg, & A. Ensio (Eds.), Connecting health and humans – Proceedings of NI2009 – The 10th International Congress on Nursing Informatics (Vol. 146, pp. 342–346). Retrieved February 1, 2011, from http://www.booksonline.iospress.nl/Content/View.aspx?piid=12605
   Google Scholar
• Health and Disability Commissioner. (2009). Poor documentation search. Retrieved June 9, 2010, from http://www.hdc.org.nz
   Google Scholar
• Hellesø, R., & Ruland, C. M. (2001). Developing a module for nursing documentation integrated in the electronic patient record. Journal of Clinical Nursing, 10(6), 799–805.
   Google Scholar
• Hensen, P., Ma, H. L., Luger, T. A., Roeder, N., & Steinhoff, M. (2005). Pathway management in ambulatory wound care: Defining local standards for quality improvement and interprofessional care. International Wound Journal, 2(2), 104–111.
   Google Scholar
• Hoban, V. (2003). How to improve your record keeping. Nursing Times, 99(42), 78–79.
   Google Scholar
• Idvall, E., & Ehrenberg, A. (2002). Nursing documentation of post operative pain management. Journal of Clinical Nursing, 11, 734–742.
   Google Scholar
• Ioanna, P., Stiliani, K., & Vasiliki, B. (2007). Nursing documentation and recording systems of nursing care. Health Science Journal, 4(1), 7.
   Google Scholar
• Jacks, M. E., Blue, C., & Murphy, D. (2008). Short and long-term effects of training on dental hygiene faculty members capacity to write SOAP notes. Journal of Dental Education, 72(6), 719–724.
   Google Scholar
• Kärkkäinen, O., & Eriksson, K. (2005). Recording the content of the caring process. Journal of Nursing Management, 13, 202–208.
   Google Scholar
• Karlsen, R. (2007). Improving nursing documentation: Professional consciousness-raising in a northern-Norwegian psychiatric hospital. Journal of Psychiatric and Mental Health Nursing, 14, 573–577.
   Google Scholar
• Kassam, R., Farris, K. B., Burback, L., Volume, C. I., Cox, C. E., & Cave, A. (2001). Pharmaceutical care research and education project: Pharmacists interventions. Journal of the American Pharmaceutical Association, 41(3), 401–410.
   Google Scholar
• Kelly, T. F, Brandon, D. H., & Docherty, S. L. (2011). Electronic Nursing Documentation as a strategy to improve quality patient care. Journal of Nursing Scholarship, 43(2), 154–162.
   Google Scholar
• Kuhn, I. F. (2007). Abbreviations and acronyms in health care: When shorter isn’t sweeter. Paediatric Nursing, 33(5), 329–398.
   Google Scholar
• Laitinen, H., Kaunonen, M., & Astedt-Kurki, P. (2010). Patient focused nursing documentation expressed by nurses. Journal of Clinical Nursing, 19(3–4), 489–497.
   Google Scholar
• Lampe, S. (1997). Focus charting: Documentation for patient centred care (7th ed.). Minneapolis, MN: Creative Nursing Management.
   Google Scholar
• Laughlin, J., & Van Nuil, M. (2003). Boost regulatory compliance with electronic nursing documentation. Nursing Management, 34(12), 51–52.
   Google Scholar
• Lee, T. (2005). Nursing diagnoses: Factors affecting their use in charting standardised care plans. Journal of Clinical Nursing, 14, 640–647.
   Google Scholar
• McGeehan, R. (2007). Best practice in record-keeping. Nursing Standard, 21(7), 51–55.
   Google Scholar
• Meurier, C. E. (1998). The quality of assessment of patients with chest pain: The development of a questionnaire to audit the nursing assessment record of patients with chest pain. Journal of Advanced Nursing, 27, 140–146.
   Google Scholar
• Middleton, S., Barnette, J., & Reeves, D. (2001). What is an integrated care pathway? Evidence-based Medicine, 3(3), 1–8.
   Google Scholar
• Mosby. (2006). Mosbys surefire documentation: How, what, and when nurses need to document. St Louis, MO: Author.
   Google Scholar
• Müller-Staub, M., Needham, I., Odenbriet, Lavin, M., & van Achterberg, T. (2007). Improved quality of nursing documentation: Results of a nursing diagnosis, interventions, and outcomes implementation study. International Journal of Nursing Terminologies and Classifications, 18(1), 5–17.
   Google Scholar
• New Zealand Government. (1994). Health and Disability Commissioner Act. Wellington, New Zealand: Author.
   Google Scholar
• New Zealand Nurses Organisation. (1998). Documentation: A five year saga for health professionals (Pamphlet). Wellington, New Zealand: Author.
   Google Scholar
• Nurses Board of South Australia [NBSA]. (2006). Guiding principles for documentation. Adelaide, SA: Author.
   Google Scholar
• Owen, K. (2005). Documentation in nursing practice. Nursing Standard, 19(32), 48–49.
   Google Scholar
• Paans, W., Nieweg, R., Van der Schans, C. P., & Sermeus, W. (2011). What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review. Journal of Clinical Nursing, 20, 2386–2403.
   Google Scholar
• Pelletier, D., Duffield, C., & Donoghue, J. (2005). Documentation and the transfer of clinical information in two aged care settings. Australian Journal of Advanced Nursing, 22(4), 40–45.
   Google Scholar
• Pennels, C. (2001). The art of recording patient care information. Professional Nurse, 16(9), 1359–1361.
   Google Scholar
• Reamer, F. G. (2005). Documentation in social work: Evolving ethical and risk management standards. Social Work, 50(4), 325–334.
   Google Scholar
• Reed, R. D. (1991). A standards of care plan in the post anaesthesia care unit. Journal of Post Anaesthesia Nursing, 6(4), 255–264.
   Google Scholar
• Rykkje, L. (2009). Implementing electronic patient record and VIPS in medical hospital wards: Evaluating change in quantity and quality of nursing documentation by using the audit instrument cat-ch-ing. Vård I Norden, 29(2), 9–13.
   Google Scholar
• Spencer, J. A., & Lunsford, V. (2010). Electronic documentation and the caring nurse-patient relationship. International Journal for Human Caring, 14(2), 30–35.
   Google Scholar
• Thoma, D., & Pittman, K. (1972). Evaluation of problem-orientated nursing notes. Journal of Nursing Administration, 2(3), 50–58.
   Google Scholar
• Tingle, J. H. (2001). Record keeping should be a key skill not a chore. British Journal of Nursing, 10(21), 1378.
   Google Scholar
• Tranter, S. (2009). A hospital wide nursing documentation project. Australian Nursing Journal, 17(5), 34–36.
   Google Scholar
• Trossman, S. (2002). The documentation dilemma: Nurses poised to address paperwork burden. Nevada RN Information, 11(1), 5–6.
   Google Scholar
• Van der Wal, R., Dalzeal, S., & Kitzul M. (2009). Implementing an interdisciplinary electronic documentation system at two pilot units within an acute care setting. Advances in Information Technology and Communication in Health, 143, 192–197.
   Google Scholar
• Wang, N., Hailey, D., & Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: A mixed-method systematic review. Journal of AdvancedNursing, 67(9), 1858–1875.
   Google Scholar
• Whittaker, A. A., Aufdenkamp, M., & Tinley, S. (2009). Barriers and facilitators to electronic documentation in a rural hospital. Journal of Nursing Scholarship, 41(3), 293–300.
   Google Scholar
• Wilson, J. (1998). Proactive risk management: Documentation of patient care. British Journal of Nursing, 7(13), 797–798.
   Google Scholar
• Wood, C. (2002). The importance of good record keeping for nurses. Nursing Times, 99(2), 26–27.
   Google Scholar