Quality of the documentation of the Nursing process in clinical decision support systems

Oliveira, Neurilene Batista de; Peres, Heloísa Helena Ciqueto

doi:10.1590/1518-8345.4510.3426

Brasil

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Original Article • Rev. Latino-Am. Enfermagem 29 • 2021 • https://doi.org/10.1590/1518-8345.4510.3426 linkcopy

Quality of the documentation of the Nursing process in clinical decision support systems^*

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: to compare the quality of the Nursing process documentation in two versions of a clinical decision support system.

Method: a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics.

Results: the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated.

Conclusion: the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.

Descriptors: Decision Support Systems, Clinical; Nursing Process; Standardized Nursing Terminology; Electronic Health Records; Nursing Informatics; Technology Assessment, Biomedical

Items of Nursing Diagnosis as a Process	Variables	Pre		Post		p-value
Items of Nursing Diagnosis as a Process	Variables	n	%	n	%	p-value
1 Current situation that led to hospitalization	Not documented	2	2.47	0	0.00	0.046^* * Fisher' Exact Test;
	Partially documented	65	80.25	39	67.24
	Complete documentation	14	17.28	19	32.76
2 Anxiety, concerns, expectations and desires related to hospitalization	Not documented	57	70.37	23	39.66	0.001^† † Pearson' Chi-Square Test
	Partially documented	21	25.93	32	55.17
	Complete documentation	3	3.70	3	5.17
3 Social situation and environment, circumstances in which you live	Not documented	30	37.04	0	0.00	0.001^* * Fisher' Exact Test;
	Partially documented	49	60.49	55	94.83
	Complete documentation	2	2.47	3	5.17
4 Facing the current situation with the disease	Not documented	65	80.25	9	15.52	0.001^† † Pearson' Chi-Square Test
	Partially documented	15	18.52	42	72.41
	Complete documentation	1	1.24	7	12.07
5 Belief and attitudes towards life (related to hospitalization)	Not documented	18	22.22	5	8.62	0.028^* * Fisher' Exact Test;
	Partially documented	63	77.78	52	89.66
	Complete documentation	0	0.00	1	1.72
6 Information from the patient and family members/significant people about the situation	Not documented	65	80.25	18	31.03	0.001^* * Fisher' Exact Test;
	Partially documented	16	19.75	27	46.55
	Complete documentation	0	0.00	13	22.41
7 Gender-related personal intimacy issue	Not documented	81	100.00	58	100.00	1.000^* * Fisher' Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	0	0.00	0	0.00
8 Hobbies, leisure activity	Not documented	81	100.00	58	100.00	1.000^* * Fisher' Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	0	0.00	0	0.00
9 Important people (for contact)	Not documented	21	25.93	0	0.00	0.001^* * Fisher' Exact Test;
	Partially documented	59	72.84	25	43.10
	Complete documentation	1	1.24	33	56.90
10 Activities of daily living	Not documented	38	46.91	20	34.48	0.049^† † Pearson' Chi-Square Test
	Partially documented	15	18.52	6	10.34
	Complete documentation	28	34.57	32	55.17
11 Relevant nursing priorities according to the assessment	Not documented	0	0.00	0	0.00	1.000^* * Fisher' Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	81	100.00	58	100.00

Nursing Diagnosis as a Product	Variables	Pre		Post		p-value
Nursing Diagnosis as a Product	Variables	n	%	n	%	p-value
12 The nursing problem/diagnosis title is recorded	Not documented	0	0.00	0	0.00	1.000^* * Fisher's Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	81	100.00	58	100.00
13 The diagnostic title is formulated and numbered according to NANDA^† † NANDA International	Not documented	0	0.00	0	0.00	1.000^* * Fisher's Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	81	100.00	58	100.00
14 The etiology is registered	Not documented	6	7.41	0	0.00	0.016^* * Fisher's Exact Test;
	Partially documented	3	3.70	0	0.00
	Complete documentation	72	88.89	58	100.00
15 The etiology is correct and corresponds to the nursing diagnosis	Not documented	6	7.41	0	0.00	0.016^* * Fisher's Exact Test;
	Partially documented	3	3.70	0	0.00
	Complete documentation	72	88.89	58	100.00
16 The signs and symptoms are recorded	Not documented	1	1.24	0	0.00	1.000^* * Fisher's Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	80	98.77	58	100.00
17 The signs and symptoms are correct and related to the nursing diagnosis	Not documented	0	0.00	0	0.00	1.000^* * Fisher's Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	81	100.00	58	100.00
18 The nursing goal is related/corresponds to the nursing diagnosis	Not documented	2	2.47	0	0.00	0.510^* * Fisher's Exact Test;
	Partially documented	1	1.24	0	0.00
	Complete documentation	78	96.30	58	100.00
19 The nursing goal is attainable by means of the interventions	Not documented	2	2.47	0	0.00	0.510^* * Fisher's Exact Test;
	Partially documented	1	1.24	0	0.00
	Complete documentation	78	96.30	58	100.00

Nursing Interventions	Variables	Pre		Post		p-value
Nursing Interventions	Variables	n	%	n	%	p-value
20 Concrete, clearly named according to the NIC^† † Nursing Interventions Classification interventions and planned	Not documented	1	1.24	0	0.00	0.001^* * Fisher's Exact Test;
	Partially documented	13	16.05	0	0.00
	Complete documentation	67	82.72	58	100.00
21 The nursing interventions have an effect on the etiology of the nursing diagnoses	Not documented	2	2.47	0	0.00	0.428^* * Fisher's Exact Test;
	Partially documented	2	2.47	0	0.00
	Complete documentation	77	95.06	58	100.00
22 The nursing interventions performed are recorded	Not documented	2	2.47	0	0.00	0.510^* * Fisher's Exact Test;
	Partially documented	1	1.24	0	0.00
	Complete documentation	78	96.30	58	100.00

Nursing Outcomes	Variables	Pre		Post		p-value
Nursing Outcomes	Variables	n	%	n	%	p-value
23 Critical diagnostic changes are evaluated daily or shift by shift	Not documented	0	0.00	0	0.00	1.000^* * Fisher's Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	81	100.00	58	100.00
24 The nursing diagnosis is reformulated	Not documented	0	0.00	0	0.00	1.000^* * Fisher's Exact Test;
	Partially documented	0	0.00	0	0.00
	Complete documentation	81	100.00	58	100.00
25 The nursing result is recorded	Not documented	0	0.00	0	0.00	0.001^* * Fisher's Exact Test;
	Partially documented	81	100.00	0	0.00
	Complete documentation	0	0.00	58	100.00
26 The nursing outcome is observable/measured according to the NOC^† † Nursing Interventions Classification	Not documented	0	0.00	0	0.00	0.001^* * Fisher's Exact Test;
	Partially documented	81	100.00	0	0.00
	Complete documentation	0	0.00	58	100.00
27 The nursing outcome indicates improvement	Not documented	58	71.61	0	0.00	0.001^* * Fisher's Exact Test;
	Partially documented	18	22.22	16	27.59
	Complete documentation	5	6.17	42	72.41
28 There is a relationship between the outcomes and the nursing interventions	Not documented	4	4.94	0	0.00	0.140^* * Fisher's Exact Test;
	Partially documented	1	1.24	0	0.00
	Complete documentation	76	93.83	58	100.00
29 The outcomes and the nursing diagnoses are internally related	Not documented	4	4.94	0	0.00	0.140^* * Fisher's Exact Test;
	Partially documented	1	1.24	0	0.00
	Complete documentation	76	93.83	58	100.00

Q-DIO^* * Q-DIO = Quality of Diagnoses, Interventions and Outcomes; domains	Moment	n	Mean	Standard Deviation	Median	p-value
Nursing Diagnosis as a Process	Pre-intervention	81	6.95	1.65	7	< 0.001^† † Two sample Welch t-test;
Nursing Diagnosis as a Process	Post-intervention	58	10.62	2.25	11	< 0.001^† † Two sample Welch t-test;
Nursing Diagnosis as a Product	Pre-intervention	81	15.48	1.32	16	< 0.001^‡ ‡ Brunner-Munzel test;
Nursing Diagnosis as a Product	Post-intervention	58	16.00	0.00	16	< 0.001^‡ ‡ Brunner-Munzel test;
Nursing Interventions	Pre-intervention	81	5.68	0.88	6	< 0.001^‡ ‡ Brunner-Munzel test;
Nursing Interventions	Post-intervention	58	6.00	0.00	6	< 0.001^‡ ‡ Brunner-Munzel test;
Nursing Outcome	Pre-intervention	81	10.12	1.08	10	<0.001^§ § Wilcoxon-Mann-Whitney test
Nursing Outcome	Post-intervention	58	13.72	0.45	14	<0.001^§ § Wilcoxon-Mann-Whitney test
Total	Pre-intervention	81	38.24	3.00	39	<0.001^§ § Wilcoxon-Mann-Whitney test
Total	Post-intervention	58	46.35	2.29	46.5	<0.001^§ § Wilcoxon-Mann-Whitney test

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[TFN1] ^*
Fisher' Exact Test;

[TFN2] ^†
Pearson' Chi-Square Test

Quality of the documentation of the Nursing process in clinical decision support systems*

Quality of the documentation of the Nursing process in clinical decision support systems^*