Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment
To access publisher full text version of this article. Please click on the hyperlink in Additional Links field AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nor...
Published in: | Scandinavian Journal of Caring Sciences |
---|---|
Main Authors: | , , , , , , , , |
Other Authors: | |
Format: | Article in Journal/Newspaper |
Language: | English |
Published: |
Taylor & Francis
2011
|
Subjects: | |
Online Access: | http://hdl.handle.net/2336/125816 https://doi.org/10.1111/j.1471-6712.2007.00534.x |
id |
ftlandspitaliuni:oai:www.hirsla.lsh.is:2336/125816 |
---|---|
record_format |
openpolar |
spelling |
ftlandspitaliuni:oai:www.hirsla.lsh.is:2336/125816 2023-05-15T16:48:44+02:00 Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment Jensdottir, Anna-Birna Jonsson, Palmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne-Soveri, Harriet Schroll, Marianne Grue, Else Bjornsson, Jan Sóltún Nursing Home, Reykjavík, Iceland. annabirna@soltun.is 2011-04-28 http://hdl.handle.net/2336/125816 https://doi.org/10.1111/j.1471-6712.2007.00534.x en eng Taylor & Francis http://dx.doi.org/10.1111/j.1471-6712.2007.00534.x Scand J Caring Sci. 2008, 22(3):341-7 1471-6712 18840217 doi:10.1111/j.1471-6712.2007.00534.x http://hdl.handle.net/2336/125816 Scandinavian journal of caring sciences Activities of Daily Living Aged 80 and over Critical Care Data Collection Documentation Female Finland Frail Elderly Humans Iceland Male Medical Records Medical Staff Hospital Nursing Process Physicians Questionnaires Article 2011 ftlandspitaliuni https://doi.org/10.1111/j.1471-6712.2007.00534.x 2022-05-29T08:21:43Z To access publisher full text version of this article. Please click on the hyperlink in Additional Links field AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. METHOD: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. FINDINGS: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases. CONCLUSIONS: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care. Article in Journal/Newspaper Iceland Hirsla - Landspítali University Hospital research archive Scandinavian Journal of Caring Sciences 22 3 341 347 |
institution |
Open Polar |
collection |
Hirsla - Landspítali University Hospital research archive |
op_collection_id |
ftlandspitaliuni |
language |
English |
topic |
Activities of Daily Living Aged 80 and over Critical Care Data Collection Documentation Female Finland Frail Elderly Humans Iceland Male Medical Records Medical Staff Hospital Nursing Process Physicians Questionnaires |
spellingShingle |
Activities of Daily Living Aged 80 and over Critical Care Data Collection Documentation Female Finland Frail Elderly Humans Iceland Male Medical Records Medical Staff Hospital Nursing Process Physicians Questionnaires Jensdottir, Anna-Birna Jonsson, Palmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne-Soveri, Harriet Schroll, Marianne Grue, Else Bjornsson, Jan Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
topic_facet |
Activities of Daily Living Aged 80 and over Critical Care Data Collection Documentation Female Finland Frail Elderly Humans Iceland Male Medical Records Medical Staff Hospital Nursing Process Physicians Questionnaires |
description |
To access publisher full text version of this article. Please click on the hyperlink in Additional Links field AIM: To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. METHOD: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. FINDINGS: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases. CONCLUSIONS: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care. |
author2 |
Sóltún Nursing Home, Reykjavík, Iceland. annabirna@soltun.is |
format |
Article in Journal/Newspaper |
author |
Jensdottir, Anna-Birna Jonsson, Palmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne-Soveri, Harriet Schroll, Marianne Grue, Else Bjornsson, Jan |
author_facet |
Jensdottir, Anna-Birna Jonsson, Palmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne-Soveri, Harriet Schroll, Marianne Grue, Else Bjornsson, Jan |
author_sort |
Jensdottir, Anna-Birna |
title |
Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
title_short |
Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
title_full |
Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
title_fullStr |
Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
title_full_unstemmed |
Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
title_sort |
comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment |
publisher |
Taylor & Francis |
publishDate |
2011 |
url |
http://hdl.handle.net/2336/125816 https://doi.org/10.1111/j.1471-6712.2007.00534.x |
genre |
Iceland |
genre_facet |
Iceland |
op_relation |
http://dx.doi.org/10.1111/j.1471-6712.2007.00534.x Scand J Caring Sci. 2008, 22(3):341-7 1471-6712 18840217 doi:10.1111/j.1471-6712.2007.00534.x http://hdl.handle.net/2336/125816 Scandinavian journal of caring sciences |
op_doi |
https://doi.org/10.1111/j.1471-6712.2007.00534.x |
container_title |
Scandinavian Journal of Caring Sciences |
container_volume |
22 |
container_issue |
3 |
container_start_page |
341 |
op_container_end_page |
347 |
_version_ |
1766038826233364480 |