Attitude Towards Documentation and Its Associated Factors Among Nurses Working in Public Hospitals of Hawassa City Administration, Southern Ethiopia

The Documentation Used by the Nurses During the Transition From the Hospital to the Community Setting: A Scoping Review

AIM

This study aimed to identify the content of documentation used between hospital and community care and describe the communication mechanisms that allow the continuity of care.

DESIGN

We conducted a scoping review following the JBI recommendations.

METHODS

The sources of the information used were obtained from the MEDLINE and CINAHL databases (via EBSCO), Web of Science, SCOPUS, Joanna Briggs Institute and Cochrane Database of Systematic Reviews. Additionally, grey literature was included. The databases searched from 2018 to 2023 for articles written in English and Portuguese. Two researchers independently screened articles based on inclusion and exclusion criteria, and a third researcher adjudicated disagreements.

RESULTS

We retrieved 3217 articles, of which 5 were included. Six themes were summarised from these articles: Communication and information between clinical practice environments; Discharge letter content; The use of technologies in healthcare communication; Client empowerment in information communication; Factors hindering the safe transition of information between hospital and community; and Benefits of secure information transition between hospital and community.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results allow systematisation of the information that should accompany the person at the time of discharge to ensure the continuity of transitional care, including the patient/family's own perception of their difficulties and needs.

REPORTING METHOD

PRISMA 2020.

Experiences of operational managers regarding record keeping by new professional nurses in public hospitals in the North West province, South Africa

Background

Documentation can be written or computerised and is used to communicate healthcare and treatment among healthcare professionals. Documentation is the tool that records and measures the healthcare provided to patients, and it must be accurate, complete and timely.

Aim

This study aims to explore and describe the experiences of the operational managers regarding record keeping by new nurses in selected public hospitals in South Africa.

Setting

The study was conducted in selected public hospitals in the North West province.

Method

This study used a qualitative, explorative and descriptive approach with a purposive sampling method. A total of 35 operational managers participated in the process of data collection.

Results

The following themes emerged from this study: gaps in record keeping, the impact of inaccurate documentation and the need for improvement in record keeping.

Conclusion

The study has shown the need to bring technological innovation to strengthen the effective improvement of digitalisation in nursing record keeping in the facilities furthermore, nurses should be supported through programmes on intentional and mindful record keeping curbing the incidences of inaccuracy and incompleteness.

Contribution

This study's findings confirmed that new nurses were not consistent with accurate documentation of patient records, and this needs further strengthening in public hospitals to have an impact on the health and safety of the patient.

Procedure Code Utilization for Vascular Access Device Placement in the Inpatient Setting: A Retrospective Analysis

Vascular access (VA) is essential to inpatient care, and the documentation/coding practices for vascular access device (VAD) placement procedures remain unexplored. Accurate documentation may present benefits for patients, providers, and researchers. A retrospective analysis was performed in adult inpatients (2015 to 2020) using Cerner Real World Data™ to evaluate the utilization of CPT codes for VAD placement/replacement procedures. A total of 14,253,584 patient encounters were analyzed, 0.111 percent (n=15,833) of which received at least one VAD procedure code. Non-tunneled CVC procedures had the highest code rate (0.067 percent), while PIV/midline procedures were the least likely to be coded (0.004 percent). The annual proportion of code utilization increased from 10.9 percent in 2015 to 19.7 percent in 2020 (p<0.0001). Despite widespread use of VADs in the inpatient setting, the procedure coding rate was found to be remarkably low. Appropriate coding/documentation practices may ensure proper care by capturing VA-related patient history, and improve research quality and resource/staff allocation.

Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021

Introduction

Medical documentation is an important part of the medical process as it is an essential way of communication within the health care system. However, medical documentation practice in the private sector is not well studied in Ethiopian context. The aim of this study was to assess the practice of medical documentation and its associated factors among health workers at private hospitals in the Amhara region, Ethiopia.

Method

An institution-based cross-sectional quantitative study supplemented with a qualitative design was conducted among 419 health workers at the private hospitals in the Amhara Region, Ethiopia from March 29 to April 29 /2021. Data were collected using both a self-administered questionnaire and interview guide for quantitative and qualitative respectively. Data were entered using Epi data version 3.1 and analyzed using SPSS version 20. Descriptive statistics, Bi-variable, and multivariable logistic regression analysis were performed. In-depth interviews were conducted using semi-structured questionnaires with eight respondents to explore the challenges related to the practice of medical documentation. Respondent’s response were analyzed using OpenCode version 4.03 thematically.

Results

Four hundred seven study participants returned the questionnaire. Nearly 50 % (47.2%) health workers had of good medical documentation practice. Health workers who received in-service training on medical documentation AOR = 2.77(95% CI: [1.49,5.14]), good knowledge AOR = 2.28 (95% CI: [1.34,3.89]), favorable attitude AOR = 1.78 (95%CI: [1.06,2.97]), strong motivation AOR = 3.49 (95% CI: [2.10,5.80]), available guide line formats AOR = 3.12 (95% CI: [1.41,6.84]), eHealth literacy AOR = 1.73(95% CI: [1.02,2.96]), younger age AOR = 2.64 (95% CI:[1.27,5.46]) were statistically associated with medical documentation.

Conclusion

More than half of the medical services provided were not registered. Therefore, it is important to put extra efforts to improve documentation practice by providing planed trainings on standards of documentation to all health workers, creating positive attitudes and enhancing their knowledge by motivating them to develop a culture of information.