Assessment of nursing care reports in a university hospital

Section: Originals

How to quote

Martínez Arribas S, Peña Molinero C, Valiñas Sieiro F, Otero Pinto S, González Hernando S, Hormilla Martínea ML. Evaluación del Informe de Cuidados de Enfermería en un hospital universitario. Metas Enferm abr 2018; 21(3):50-7.

Authors

Sara Martínez Arribas1, Celia Peña Molinero2, Florita Valiñas Sieiro3, Sonia Otero Pinto4,Sonia González Hernando2, Mª Luz Hormilla Martínez5

Position

1Enfernera. Unidad de Cardiología. Hospital Universitario de Burgos2Enfermera. Supervisora General. Hospital Universitario de Burgos3Enfermera. Supervisora de la Unidad de Neurología y Unidad de ICTUS. Hospital Universitario de Burgos4Enfermera. Unidad de Psiquiatría. Hospital Universitario de Burgos5Enfermera. Unidad de Hospitalización a Domicilio. Hospital Universitario de Burgos

Contact address

Sara Martínez Arribas. Hospital Universitario de Burgos. Unidad de Cardiología (Bloque D, 3ª planta). Avda. Islas Baleares, 3. 09006 Burgos.

Contact email: smartineza@saludcastillayleon.es

Abstract

Objective: to assess the quality of Nursing Care Reports (NCR) completed in the hospitalization units of a university hospital, and to determine their improvement in 2016 vs. 2015.
Method: a retrospective longitudinal descriptive study was conducted, with two cut-off dates in similar periods: May, 2015 and May, 2016, in the Complejo Asistencia Universitario de Burgos. The care management program GACELA-Care was used for data collection. The quality of NCRs was analyzed based on standard criteria that were agreed upon by consensus of the team. There was a descriptive analysis of NCR quality. Chi-Square Test or Fisher’s Exact Test was used in order to assess the changes between 2015 and 2016 in terms of overall quality and variables.
Results: there was an analysis of 666 reports. There was an increase in the number of NCRs conducted: from 316 (79%) to 350 (85%) in 2016. The reports with very good quality increased from 1% (n= 4) to 17% (n= 60), and there was a reduction in the number of reports with poor quality, from 53% (n= 169) to 42% (n= 146) with p< 0.00. Overall, the variables Observations (summary) and Observations (devices, continuity of care) improved significantly in 2016 vs. 2015. The Active Assessment variable reached 75% compliance, while 13% of NCRs did not include recommendations needed by the patient at discharge.
Conclusions: NCR compliance is quite high, and improving from one year to another, though only 25% of these reports presented Good or Very Good quality. It would be advisable to plan an intervention with the aim to improve the quality in the completion of these reports.

Keywords:

continuity of patient care; healthcare quality; patient discharge summary; Nursing Care Report

Versión en Español

Título:

Evaluación del Informe de Cuidados de Enfermería en un hospital universitario