Estudio situacional de los registros electrónicos en una unidad de medicina interna: barreras y oportunidades

  1. Montserrat Pérez-Martí 1
  2. Lina Cristina Casadó Marín 2
  3. José Oriol Romaní Alfonso 2
  1. 1 Hospital Comarcal Alt Penedés. Vilafranca del Penedés. Barcelona. España
  2. 2 Universidad Rovira i Virgili.Tarragona. España.
Journal:
Enfermería global: revista electrónica trimestral de enfermería

ISSN: 1695-6141

Year of publication: 2018

Volume: 17

Issue: 3

Pages: 180-189

Type: Article

DOI: 10.6018/EGLOBAL.17.3.284211 DIALNET GOOGLE SCHOLAR lock_openDIGITUM editor

More publications in: Enfermería global: revista electrónica trimestral de enfermería

Abstract

The objective of this study was to identify the resources, workflows and perception of nurses of internal medicine unit, related to electronic records in order to determine if the implementation of tablets in hospital units could cover the nurses’ needs more satisfactorily. A descriptive, cross-sectional study with non-probability sampling was carried out during July and August of 2016. The study involved 31 observations of 18 nurses, with 392 patients admitted. The variables were: shift, working methodology, "round" time, time taken to write up data, total time, number of patients admitted and time spent per patient. Each nurse was asked how they worked and why. The average total time was 59,16 min (DT:16,6), and 12.65 (DT:1,11) patients admitted. Time spent per patient was 4,65 min (DT:1,15) and was lower during the afternoon shift [M:4,14; [DT: 0.84] than during the night shift [M: 5.47; DT: 1,12]. The night shift always used the same method of work, whereas different systems were used during the afternoon. The nurses expressed the need for a lightweight record system that would enable them to record information in real time near the patient without having to go elsewhere, and which would make it easy to consult and exchange information. The two working methods used in the observation unit do not satisfy the needs of nurses, are slow and cumbersome and make it difficult for nurses to access and record information. The adoption of tablets could reduce these problems and meet nurses’ expectations and thus opens a new line of research.

Bibliographic References

  • 1. Calero Romero MR, González FL. El registro de enfermería como parte del
  • cuidado, En: euroenfermería ante la patología tumoral y degenerativa. XXXVIII Congreso Nacional de la Asociación Española de Enfermería en neurociencias; 2014; Granada, España.
  • 2. Ortiz C O, Chávez M. El registro de enfermería como parte del cuidado. Scientia 2006;8 (2): 52-6
  • 3. Currell R, Urquhart C Sistemas de registro de enfermería: efectos sobre la práctica de la enfermería y resultados en la asistencia sanitaria (Revisión Cochrane traducida). En: La Biblioteca Cochrane Plus, 2008 Número 4. Oxford: Update Software Ltd. [citado 12 abr 2016] Disponible en: http://www.bibliotecacochrane.com/BCPGetDocument.asp?SessionID=%20115142 51&DocumentID=CD002099
  • 4. Saranto k, Ulla Mari K. Evaluating nursing documentation-research desings and methods: systemtic review. J Adv Nurs 2009; 65(3):464-76
  • 5. Amezcua M. La calidad en la documentación clínica de enfermería. Del papeleo a los registros para el cuidado. Index Enferm (edición digital) 1995; 11.
  • 6. Del Olmo SM, Casas L, Mejías A. En registro de enfermería, un sistema de comunicación. Enferm Clínica 2007, 17 (3):142-145.
  • 7. Consejo de la Profesión Enfermera de Cataluña. Indicadores de Avaluación de los Cuidados Enfermeros. Generalidad de Cataluña. Departamento de Salud. Barcelona, enero 2014. [citado 12 abr 2016]: Disponible en: http://coibazure.blob.core.windows.net/coib-publish/invar/a840d315-8fa6-4d51- ab3e-819863b23710
  • 8. Seguridad de Pacientes. [Internet]. Barcelona. Generalidad de Cataluña. [citado 20 abr 2016]: Disponible en: http://seguretatdelspacients.gencat.cat/ca/professionals/projectes_de_seguretat_d els_pacients/
  • 9. Medeiros AL, Rezende LCM, Santos SR, Nascimento NM, Costa T. Applicability of electronic medical records in health sector: an integrative review. J Nurs UFPE on line 2014; 8 (11): 3992-4000.
  • 10. Fernández M, Cibanal JL. Los sistemas de Información Guiados por el Conocimiento. El futuro de los Registros Enfermeros. Rev Tesela 2009; 5.
  • 11. Kelley F K, Drandon D H. Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care. J Nurs Scholarsh, 2011; 43:2, 154-162.
  • 12. Yeung M S, Lapinsky S E, Granton J T, Doran D M, Cafazzo J A. Examining nursing vital signs documentation workflow: barriers and opportunities in general internal medicine units. J Clin Nurs. 2012 Apr;21(7-8):975-82. doi: 10.1111/j.1365- 2702.2011.03937.x. Epub 2012 Jan 14.
  • 13. Sockolow PS, Rogers M, Bowles KH, Hand KE, George J. Challenges and facilitators to nurse use of a guideline-based nursing information system: Recommendations for nurse executives. Appl Nurs Res 2014; 27: 25-32.
  • 14. Fleischmann R; Duhm J, Hupperts Hagen, Brandt SA. Tablet computers with mobile electronic medical records enhance clinical routine and promote bedside time: a controlled prospective crossover study. J Neurol 2015; 262: 532-540.
  • 15. Stuttle B. Computers in nursing: patient data at the point of care. Prim Health Care 2009; 19 (5); 32-33.
  • 16. Dykes PC, Carroll DL, Benoit A, et al. A Randomized Trial of Standardized Nursing Patient Assessment Using Wireless Devices. J Am Med Inform Assoc Annual Symposium Proceedings. 2007;2007:206-210
  • 17. Ferreira PA, Marcon, GT; Carvalho DC. Contribuições dos registros eletrônicos para a segurança do paciente em terapia intensiva: uma revisão integrativa. Texto Contexto Enferm | 2012 | 21(4):971-979. [citado 15 oct 2015] Disponible en: http://www.index-f.com/textocontexto/2012pdf/21-971.pdf.
  • 18. Benner PE. From novice to expert: excellence and power in clinical nursing practice. Menlo Park (CA): Addison-Wesley; 1984
  • 19. Blake H. Mobile technology: streamlining practice and improving care. Br J Community Nurs 2013; 18 (9).
  • 20. Gregory D, Buckner M. Poibt-of-Care Technology. Integration for Improved Delivery of Care. Crit Care Nurs Q 2014; 37 (3); 268-272
  • 21. Haller G, Haller DM, Courvoisier DS, Lovis C. Handheld vs. Laptop Computers for Electronic Data Collection in Clinical Research: A Crossover Randomized Trial. J Am Med Inform Assoc 2009; 16 (5).
  • 22. Kohle A, Chatterjee P, Ulku H, Hochhheiser H, Bartos C. Evaluating the Barriers to Point-of-Care Documentation for Nursing Staff. Comput Inform Nurs 2012; 30 (3); 126-133