Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports

Journal of Clinical Nursing
Krystle MartinN Zoe Hilton

Abstract

To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process. The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122-1131). The project was a mixed-method, two-phase study that collected data from two sites. In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice....Continue Reading

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Citations

Jul 11, 2020·International Journal of Mental Health Nursing·Krystle Martin, Callum Stanford
Nov 30, 2019·Pharmacy : Journal of Pharmacy, Education and Practice·Mojtaba VaismoradiSue Jordan
Oct 30, 2020·Pharmacy : Journal of Pharmacy, Education and Practice·Mojtaba VaismoradiManela Glarcher
Mar 4, 2021·International Journal of Clinical Pharmacy·Sheila Feitosa RamosDivaldo Pereira de Lyra
May 25, 2021·The Canadian Journal of Nursing Research = Revue Canadienne De Recherche En Sciences Infirmières·Krystle Martin, Rosemary Ricciardelli
Jun 5, 2021·Annals of Saudi Medicine·Maryam Ali AlharaibiTariq M Alhawassi

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