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Nursing documentation in occupational health.

Denise Tolfo Silveira1, Heimar de Fátima Marin

  • 1Federal University of Rio Grande do Sul UFRGS), Doctoral Candidate UNIFESP, Brazil. dtolfo@denf.epm.br

Studies in Health Technology and Informatics
|September 15, 2005
PubMed
Summary

This study analyzed nursing documentation in patient records, finding that job history details were frequently missing. Improving documentation is crucial for quality occupational health nursing care and better population health outcomes.

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Area of Science:

  • Nursing
  • Occupational Health
  • Health Informatics

Background:

  • Nursing documentation is vital for care continuity, quality, and efficiency.
  • Global research focuses on essential data for nursing records.
  • This study analyzes nursing documentation within patient records.

Purpose of the Study:

  • To describe the analysis of nursing documentation in patient records.
  • To identify essential data for maintaining nursing care continuity and quality.
  • To assess nursing performance efficiency through documentation analysis.

Main Methods:

  • Retrospective study design.
  • Analysis of 106 patient records from ambulatory occupational health nursing, totaling 775 nursing records.
  • Evaluation of nursing records across dimensions: identification, job history, health state, health and safety, psychological/socio-cultural, medical history, physical examination, and nursing assessment.

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Main Results:

  • Higher frequency of documented data elements in health state, health and safety, physical examination, and nursing assessment dimensions.
  • Significant underdocumentation in job history: 25% lacked current work status, and other job-related details (activity, exposure, occupation, etc.) were also frequently missing.

Conclusions:

  • Highlights the importance of documenting and organizing data in occupational health nursing information systems.
  • Adequate data collection is essential for improving nursing care in this setting.
  • Enhanced documentation can contribute to better population health outcomes.