Keywords

Electronic health records, Hospital accreditation, Nursing audit, Nursing informatics, Quality of nursing care

 

Authors

  1. Nomura, Aline Tsuma Gaedke MS, RN
  2. Pruinelli, Lisiane PhD, RN
  3. da Silva, Marcos Barragan PhD, RN
  4. Lucena, Amalia de Fatima PhD, RN
  5. Almeida, Miriam de Abreu PhD, RN

Abstract

Hospital accreditation is a strategy for the pursuit of quality of care and safety for patients and professionals. Targeted educational interventions could help support this process. This study aimed to evaluate the quality of electronic nursing records during the hospital accreditation process. A retrospective study comparing 112 nursing records during the hospital accreditation process was conducted. Educational interventions were implemented, and records were evaluated preintervention and postintervention. Mann-Whitney and [chi]2 tests were used for data analysis. Results showed that there was a significant improvement in the nursing documentation quality postintervention. When comparing records preintervention and postintervention, results showed a statistically significant difference (P < .001) between the two periods. The comparison between items showed that most scores were significant. Findings indicated that educational interventions performed by nurses led to a positive change that improved nursing documentation and, consequently, better care practices.