Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

Nomura, Aline Tsuma Gaedke; Silva, Marcos Barragan da; Almeida, Miriam de Abreu

doi:10.1590/1518-8345.0686.2813

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Revista Latino-Americana de Enfermagem

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Original Articles • Rev. Latino-Am. Enfermagem 24 • 2016 • https://doi.org/10.1590/1518-8345.0686.2813 copy

Quality of nursing documentation before and after the Hospital Accreditation in a university hospital¹ 1 Paper extracted from master's thesis "Hospital Accreditation as agent for nursing record quality improvement in a university hospital.", presented to Escola de Enfermagem, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. Supported by Fundo de Incentivo à Pesquisa e Eventos (FIPE), Brazil, process # 130389.

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation, using the Quality of Nursing Diagnoses, Interventions and Outcomes - Brazilian version (Q-DIO- Brazilian version).

Method:

observational study of interventions conducted in a university hospital. Nursing documentation of 112 medical records for the period before and 112 for the period after the hospital accreditation were compared using the Q-DIO instrument - Brazilian version. Data were statistically analyzed.

Results:

there was a significant improvement in the quality of nursing documentation. When the total score of the instrument was evaluated, a significant improvement was observed in 24 out of the 29 items (82.8%).

Conclusion:

there was commitment to the shift of culture by means of the interventions carried out, which resulted in the conquest of the quality seal ensured by the Joint Commission International.

Descriptors:
Nursing Records; Nursing Audit; Hospital Accreditation; Education Department, Hospital

Escola de Enfermagem de Ribeirão Preto / Universidade de São Paulo Av. Bandeirantes, 3900, 14040-902 Ribeirão Preto SP Brazil, Tel.: +55 (16) 3315-3451 / 3315-4407 - Ribeirão Preto - SP - Brazil
E-mail: rlae@eerp.usp.br

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[1] Corresponding Author: Aline Tsuma Gaedke Nomura Hospital de Clínicas de Porto Alegre Rua Ramiro Barcelos, 2350 Bairro: Rio Branco CEP: 90035-903, Porto Alegre, RS, Brasil E-mail: anomura@hcpa.edu.br

Questions	2009 Md (P25 - P75)	2013 Md (P25 - P75)	p
Domain of Nursing diagnoses as process	5 (2 - 9)	13 (9 - 16)	<0.001
Domain of Nursing diagnoses as product	15 (13 - 16)	15 (14 - 16)	0.002
Domain of Nursing Interventions	6 (5 - 6)	6 (6 - 6)	<0.001
Domain of Nursing Outcomes	7 (4 - 9)	9 (7 - 11)	<0.001

Questions	Years	0	1	2	P
1. Actual situation leading to the hospitalization	2009	13 (11.6)	37 (33.0)	62 (55.4)	<0.001
1. Actual situation leading to the hospitalization	2013	1 (0.9)	18 (16.1)	93 (83.0)
2. Anxiety and worries related to hospitalization, expectations and desires about hospitalization	2009	54 (48.2)	31 (27.7)	27 (24.1)	<0.001
	2013	18 (16.0)	47 (42.0)	47 (42.0)
3. Social situation and living environment/circunstances	2009	67 (59.8)	31(27.7)*	14 (12.5)	<0.001
3. Social situation and living environment/circunstances	2013	37 (33.0)	44(39.3)	31 (27.7)
4. Coping situation and living environment/circunstances	2009	64 (57.1)	31 (27.7)	17 (15.2)	<0.001
4. Coping situation and living environment/circunstances	2013	19 (17.0)	49 (43.8)	44 (39.2)
5. Beliefs and attitudes about life (related to the hospitalization)	2009	93 (83)	19 (17)	0 (0)	<0.001
	2013	27 (24.1)	50 (44.6)	35 (31.3)
6. Information of the patient and relatives/significant others about the situation	2009	106 (94.6)	6 (5.4)	0 (0)	<0.001
	2013	23 (20.5)	84 (75)	5.0 (4.5)
7. Issues about personal intimacy related to gender	2009	89 (79.5)	14 (12.5)	9 (8.0)	0.665
7. Issues about personal intimacy related to gender	2013	86 (76.8)	13 (11.6)	13 (11.6)
8. Hobbies, activities for leisure	2009	81 (72.3)	24 (21.4)*	7 (6.3)	<0.001
8. Hobbies, activities for leisure	2013	46 (41.1)	36 (32.1)	30 (26.8)
9. Significant others (contact persons)	2009	85 (75.9)	14 (12.5)*	13 (11.6)	<0.001
9. Significant others (contact persons)	2013	20 (17.9)	24 (21.4)	68 (60.7)
10. Activities of daily living	2009	70 (62.5)	38 (33.9)	4 (3.6)	<0.001
10. Activities of daily living	2013	29 (25.9)	61 (54.5)	22 (19.6)
11. Relevant nursing priorities according to the assessment	2009	13 (11.6)	55 (49.1)	44 (39.3)	<0.001
11. Relevant nursing priorities according to the assessment	2013	0 (0)	22 (19.6)	90 (80.4)

Questions	Years	0	1	2	p
12. Nursing problem/ Nursing diagnosis is documented	2009	7 (6.3)	1 (0.9)*	104 (92.8)	0.036
12. Nursing problem/ Nursing diagnosis is documented	2013	1 (0.9)	0 (0)	111 (99.1)
13. Nursing diagnosis label is formulated and numbered according to NANDA.	2009	7 (6.3)	1 (0.9)*	104 (92.8)	0.036
	2013	1 (0.9)	0 (0)	111 (99.1)
14. The etiology is documented	2009	7 (6.3)	1 (0.9)*	104 (92.8)	0.036
14. The etiology is documented	2013	1 (0.9)	0 (0)	111 (99.1)
15. The etiology is correct, related and corresponding to the nursing diagnosis	2009	7 (6.3)	8 (7.1)*	97 (86.6)	0.046
	2013	1 (0.9)	5 (4.5)	106 (94.6)
16. Signs and symptoms are documented	2009	8 (7.1)	25 (22.3)*	79 (70.6)	0.023
16. Signs and symptoms are documented	2013	2 (1.8)	15 (13.4)	95 (84.8)
17. Signs and symptoms are correctly related to the nursing diagnosis	2009	9 (8.0)	24 (21.4)*	79 (70.6)	0.018
	2013	2 (1.8)	15 (13.4)	95 (84.8)
18. The nursing goal relates/corresponds to the nursing diagnosis	2009	12 (10.7)	66 (58.9)	34 (30.4)	0.002
	2013	4 (3.6)	50 (44.6)	58 (51.8)
19. The nursing goal is achievable through nursing interventions	2009	10 (8.9)	21 (18.8)*	81 (72.3)*	0.087
	2013	3 (2.7)	17 (15.2)	92 (82.1)

Questions	Years	0	1	2	p
20. Concrete, clearly named according to Nursing Interventions Classification (NIC) - and planned (what will be done, how, how often, who does it)	2009	1 (0.9)*	1 (0.9)*	110 (98.2)*	0.499
	2013	0 (0)	1 (0.9)	111 (99.1)
21. The nursing interventions affect the etiology of the nursing diagnosis	2009	8 (7.1)	11 (9.9)*	93 (83.0)*	0.033
	2013	1 (0.9)	9 (8.0)	102 (91.1)
22. Nursing interventions carried out are documented (what was done, how, how often, who did it)	2009	1 (0.9)*	22 (19.6)	89 (79.5)	<0.001
	2013	0 (0)	5 (4.5)	107 (95.5)

Questions	Years	0	1	2	P
23. Acute changing diagnosis are assessed daily or form shift to shift/ enduring diagnoses are assessed every four days	2009	8 (7.1)*	29 (25.9)*	75 (67.0)	0.057
	2013	3 (2.7)	19 (17.0)	90 (80.3)
24. The nursing diagnosis is reformulated	2009	23 (20.5)	38 (34)	51 (45.5)	<0.001
24. The nursing diagnosis is reformulated	2013	4 (3.6)	15 (13.4)	93 (83.0)
25. The nursing outcome is documented	2009	48 (42.8)	63 (56.3)	1 (0.9)	<0.001
25. The nursing outcome is documented	2013	17 (15.2)	87 (77.7)	8 (7.1)
26. The nursing outcome is observably/measurably documented according to NOC	2009	112 (100)*	0 (0)*	0 (0)*	0.498 ^(F)†
	2013	110 (98.2)	2 (1.8)	0 (0)
27. The nursing outcome shows: - improvement in patient's symptoms; - improvement of patient's knowledge; - improvement of patient's coping strategies; - improved sef-care abilities; - improved functional status	2009	85 (75.9)	14 (12.5)	13 (11.6)	<0.001
	2013	37 (33.0)	44 (39.3)	31 (27.7)
28. There is a relationship between outcomes and nursing interventions	2009	20 (17.9)	39 (34.8)*	53 (47.3)	0.005
	2013	6 (5.4)	34 (30.4)	72 (64.2)
29. The nursing outcomes and nursing diagnoses are internally related	2009	17 (15.2)	38 (33.9)*	57 (50.9)	0.005
	2013	4 (3.6)	34 (30.4)	74 (66.0)