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Published on: February 16, 2011
Use of anecdotal notes by clinical nursing faculty: a descriptive study
Mellisa A Hall1, Barbara J Daly, Elizabeth A Madigan
1University of Southern Indiana, Evansville, Indiana 47712, USA. mhall@usi.edu
The Journal of Nursing Education
|November 3, 2009
Summary
Nearly all clinical nursing faculty use anecdotal notes for student evaluation weekly. A new tool was developed to support this common, yet previously unstudied, evaluation method.
Area of Science:
- Nursing Education
- Clinical Performance Evaluation
- Qualitative Research Methods
Background:
- Anecdotal notes are widely believed to be a common tool for documenting clinical performance in nursing education.
- Empirical research on the frequency and patterns of anecdotal note usage by faculty has been lacking.
- The Context, Input, Process, Product (CIPP) evaluation model provides a framework for assessing educational practices.
Purpose of the Study:
- To investigate the frequency and patterns of anecdotal note usage by clinical nursing faculty.
- To adapt the CIPP evaluation model for application in clinical nursing education.
- To develop a supportive tool for faculty utilizing anecdotal notes in student evaluation.
Main Methods:
- A descriptive research design was employed to collect quantitative data.
- A faculty questionnaire, based on the adapted CIPP model, was developed and administered.
- Sixty-four nursing faculty from six institutions participated in the study.
Main Results:
- 97% of clinical nursing faculty reported using anecdotal notes in student evaluation.
- The majority of faculty utilize anecdotal notes on a weekly basis.
- Faculty feedback informed the development of a new tool to aid in note-taking.
Conclusions:
- Anecdotal note usage is a prevalent practice among clinical nursing faculty.
- The study highlights the need for structured support and tools for effective anecdotal note-taking.
- A faculty tool was created to enhance the process of documenting clinical performance.
Related Concept Videos
Guidelines for Nursing Documentation I
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Nursing Clinical Information System
Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Formats for Nursing Documentation
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Nursing Assessment
The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments and...
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments and...
Data Collection II
The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
Methods of Documentation IV: Focus Charting
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
It typically involves three columns for recording information:
