Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Experiment Videos

Nursing documentation in patient records

G Nordström, A Gardulf

    Scandinavian Journal of Caring Sciences
    |January 1, 1996
    PubMed
    Summary
    This summary is machine-generated.

    Accurate nursing documentation is crucial for patient safety. A review of 380 records using the NoGa protocol found significant deficiencies, particularly in nursing history, diagnosis, and discharge planning.

    Related Concept Videos

    You might also read

    Related Articles

    Articles linked to this work by shared authors, journal, and citation graph.

    Sort by
    Same author

    Europe immunoglobulin map.

    Clinical and experimental immunology·2014
    Same author

    Current treatment options with immunoglobulin G for the individualization of care in patients with primary immunodeficiency disease.

    Clinical and experimental immunology·2014
    Same author

    Health-related quality of life (HRQL) in immunodeficient adults with selective IgA deficiency compared with age- and gender-matched controls and identification of risk factors for poor HRQL.

    Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation·2013
    Same author

    Clinical symptoms in adults with selective IgA deficiency: a case-control study.

    Journal of clinical immunology·2013
    Same author

    Mortality in alcohol use disorder in the Lundby Community Cohort--a 50 year follow-up.

    Drug and alcohol dependence·2011
    Same author

    Education for dialysis patients lowers long-term phosphate levels and maintains health-related quality of life.

    Clinical nephrology·2011

    Area of Science:

    • Nursing
    • Healthcare Quality
    • Documentation Standards

    Background:

    • Effective nursing documentation is essential for safe patient care and continuity.
    • Inadequate documentation can lead to errors and compromise patient outcomes.
    • Standardized tools are needed to assess the quality of nursing records.

    Purpose of the Study:

    • To evaluate the quality of nursing documentation using the NoGa protocol.
    • To identify specific areas of deficiency in nurses' records.
    • To assess the utility of the NoGa protocol as an audit tool.

    Main Methods:

    • A survey of 380 nursing records was conducted.
    • The NoGa protocol was employed to review documentation quality.
    • Deficiencies in nursing history, status, interventions, diagnosis, goals, and discharge notes were identified.

    Related Experiment Videos

    Main Results:

    • Significant documentation deficiencies were found in most records reviewed.
    • Nursing history, status, and planned interventions were inadequate in two-thirds of records.
    • Nursing diagnosis, goals, and discharge notes were particularly poorly documented.

    Conclusions:

    • The NoGa protocol is an effective and user-friendly audit tool for assessing nursing documentation.
    • Educational programs can be evaluated for their impact on documentation quality using this protocol.
    • Addressing identified deficiencies is critical for improving the standard of nursing care.