Alexandra Gonzalez Aguna, Jorge Luis Gomez Gonzalez, M Lourdes Jimenez Rodriguez, Marta Fernandez Batalla and Adriana cercas Duque
University of Alcala, Spain
Scientific Tracks Abstracts: J Nurs Care
The realization of reports that contain the clinical cases attended over the period of family and community nursing studies is important. The problem of being a highly variable population makes these case reports hardly homogenized while data collection. The manual construction of cases in natural language is highly costly to generate a sufficient number of clinical documentation. However, this tool should generate a report describing the event that resembled as much as possible the natural language clinician. Aim: The aim is to validate a tool to document clinical cases in natural language through of the standardized fields. Methodology: Transversal descriptive type of study was done with 84 cases during the month of June and July 2014. Study variables were, Independent: basic conditioning factors, care variables, vital process, and time to complete the report; and dependents: quality report. Results: The data collected was a quantitative analysis in terms of three types of items in standardized language. Standard was established as the number of each item data were collected with the tool. Later, that standard was compared with manually collected data by residents of family and community nurses. Conclusions: The results reflect the difficulty in specifying the relevant data of a clinical case. This also demonstrates the need for a formal structure to improve the quality of clinical reports. With this tool it improves the efficiency and quality in the writing of the clinical cases, virtual newsroom versus classical writing, has been demonstrated by this study.
RN MSc Alexandra GonzálezAguña is PhD student in Computer Science Department in Alcala University.
Journal of Nursing & Care received 4230 citations as per Google Scholar report
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