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Unstructured clinical data such as nursing notes are relatively less explored for building a predictive model for post-discharge mortality despite containing rich information about the health of th...

We aimed to create and validate a natural language processing algorithm to extract wound infection‐related information from nursing notes. We also estimated wound infection prevalence in homecare settings and described related patient characteristics. In this retrospective cohort study, a natural language processing algorithm was developed and validated against a gold standard testing set. Cases with wound infection were identified using the algorithm and linked to Outcome and Assessment Information Set data to identify related patient characteristics. The final version of the natural language processing vocabulary contained 3914 terms and expressions related to the presence of wound infection. The natural language processing algorithm achieved overall good performance (F‐measure = 0.88). The presence of wound infection was documented for 1.03% (n = 602) of patients without wounds, for 5.95% (n = 3232) of patients with wounds, and 19.19% (n = 152) of patients with wound‐related hospitalisation or emergency department visits. Diabetes, peripheral vascular disease, and skin ulcer were significantly associated with wound infection among homecare patients. Our findings suggest that nurses frequently document wound infection‐related information. The use of natural language processing demonstrated that valuable information can be extracted from nursing notes which can be used to improve our understanding of the care needs of people receiving homecare. By linking findings from clinical nursing notes with additional structured data, we can analyse related patients' characteristics and use them to develop a tailored intervention that may potentially lead to reduced wound infection‐related hospitalizations.

Objective Electronic health record documentation by intensive care unit (ICU) clinicians may predict patient outcomes. However, it is unclear whether physician and nursing notes differ in their ability to predict short-term ICU prognosis. We aimed to investigate and compare the ability of physician and nursing notes, written in the first 48 hours of admission, to predict ICU length of stay and mortality using 3 analytical methods. Materials and Methods This was a retrospective cohort study with split sampling for model training and testing. We included patients ≥18 years of age admitted to the ICU at Beth Israel Deaconess Medical Center in Boston, Massachusetts, from 2008 to 2012. Physician or nursing notes generated within the first 48 hours of admission were used with standard machine learning methods to predict outcomes. Results For the primary outcome of composite score of ICU length of stay ≥7 days or in-hospital mortality, the gradient boosting model had better performance than the logistic regression and random forest models. Nursing and physician notes achieved area under the curves (AUCs) of 0.826 and 0.796, respectively, with even better predictive power when combined (AUC, 0.839). Discussion Models using only nursing notes more accurately predicted short-term prognosis than did models using only physician notes, but in combination, the models achieved the greatest accuracy in prediction. Conclusions Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Physicians’ and nurses’ notes are both uniquely important in mortality prediction and combining these notes can produce a better predictive model.

In medical visualization, nursing notes contain rich information about a patient’s pathological condition. However, they are not widely used in the prediction of clinical outcomes. With advances in the processing of natural language, information begins to be extracted from large-scale unstructured data like nursing notes. This study extracted sentiment information in nursing notes and explored its association with in-hospital 28-day mortality in sepsis patients. The data of patients and nursing notes were extracted from the MIMIC-III database. A COX proportional hazard model was used to analyze the relationship between sentiment scores in nursing notes and in-hospital 28-day mortality. Based on the COX model, the individual prognostic index (PI) was calculated, and then, survival was analyzed. Among eligible 1851 sepsis patients, 580 cases suffered from in-hospital 28-day mortality (dead group), while 1271 survived (survived group). Significant differences were shown between two groups in sentiment polarity, Simplified Acute Physiology Score II (SAPS-II) score, age, and intensive care unit (ICU) type (all P < 0.001 ). Multivariate COX analysis exhibited that sentiment polarity (HR: 0.499, 95% CI: 0.409-0.610, P < 0.001 ) and sentiment subjectivity (HR: 0.710, 95% CI: 0.559-0.902, P = 0.005 ) were inversely associated with in-hospital 28-day mortality, while the SAPS-II score (HR: 1.034, 95% CI: 1.029-1.040, P < 0.001 ) was positively correlated with in-hospital 28-day mortality. The median death time of patients with PI ≥ 0.561 was significantly earlier than that of patients with PI < 0.561 (13.5 vs. 49.8 days, P < 0.001 ). In conclusion, sentiments in nursing notes are associated with the in-hospital 28-day mortality and survival of sepsis patients.

Abstract Background There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. Methods This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting. Discussion We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. Trial registration Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

In this chapter, we examine discursive constructions of detained patients and their relationships with the nursing staff using notes written by nurses. Our study is anchored within Critical Discourse Studies (CDS), still often referred to as Critical Discourse Analysis (CDA), an interdisciplinary approach to the study of discourse as a form of social practice (Fairclough 1989, 1992). CDS is concerned with the role of language and discourse in shaping society (Krzyzanowski 2010). Van Dijk (2015) argues that CDS is a discourse study with an attitude and discourse analysts’ aim to understand, expose and—in consequence—challenge social inequality (van Dijk 2015). Critique in CDS can be understood as both normative, as CDS is concerned with evaluating the extra-linguistic realities, and explanatory, as it also looks for explanations of what is revealed (Fairclough 2012).

Objetivos: identificar os principais problemas enfrentados pela auditoria em saude e demostrar como o processo de credenciamento impacta diretamente na qualidade da assistencia prestada. Metodo: revisao integrativa da literatura, realizada em duas bases de dados e uma biblioteca virtual, de acesso aberto, tendo como criterio de inclusao: responder a questao norteadora. A amostra final foi composta de 14 artigos. Resultados: da sintese das evidencias, emergiram oito categorias aos quais demonstraram a ausencia dos seguintes criterios: anotacoes de enfermagem, definicao de protocolos, avaliacao da qualidade, satisfacao do usuario, definicao de materiais e medicamentos, adocao de pacotes e requisitos minimos necessarios a contratacao. Conclusao: o servico de auditoria desempenha papel vital na elaboracao dos processos de credenciamento, sendo importante que os gestores de contratos e os auditores estejam interligados em prol de identificar os pontos fracos e dirimir as deficiencias, buscando contribuir para que a organizacao atinja o maximo de sua eficiencia. Palavras-chaves : Auditoria; Qualidade; Saude; Eficiencia. ABSTRACT Objectives: to identify the main problems faced by the health audit and to demonstrate how the accreditation process directly impacts the quality of care provided. Method: integrative literature review, carried out in two databases and a virtual library, open access, with the inclusion criterion: answering the guiding question. The final sample consisted of 14 articles. Results: from the synthesis of the evidence, eight categories emerged which demonstrated the absence of the following criteria: nursing notes, definition of protocols, quality assessment, user satisfaction, definition of materials and medicines, adoption of packages and minimum requirements necessary for contracting. Conclusion: the audit service plays a vital role in the elaboration of the accreditation processes, being important that the contract managers and the auditors are interconnected in order to identify the weaknesses and resolve the deficiencies, seeking to contribute to the organization reaches maximum efficiency. Keywords : Audit, Accreditation, Health, Efficiency.

When it comes to assessing General Internal Medicine (GIM) patients’ state, physicians often rely on structured, time series physiological data because it’s more efficient and requires less effort to review than unstructured nursing notes. However, these text-based notes can have important information in predicting a patient’s outcome. Therefore, in this paper we train two convolutional neural networks (CNN) on in-house hospital nursing notes and physiological data with temporally segmented sliding windows to understand the differences. And we visualize the process in which deep models generate the outcome prediction through interpretable gradient-based visualization techniques. We find that the notes model provides overall better predictions results and it is capable of sending warnings for crashing patients in a more timely manner. Also, to illustrate the different focal points of the models, we identified the top contributing factors each deep model utilizes to make predictions.

Objective: to analyze the relationship between knowledge and the adequacy of nursing annotations and their determinants. Method: An exploratory, descriptive and quantitative approach, carried out in the Medical Clinic and in the Adult Intensive Care Unit of a Brazilian university hospital. A total of 114 professionals and 41 medical records were included. Results: The professionals had a high mean score of knowledge and a low mean score of adequacy and there was no correlation between them (rs = -0,122; p > 0.05). The knowledge score was higher for professionals graduated in Nursing. The mean score of adequacy was higher for the professional category nurse if packed in Medical Clinic and with the professional that was dissatisfied with the training. Conclusion: there is no relationship between the professional's knowledge about nursing notes and the adequacy of the notes, which leads to serious ethical, legal and patient safety issues.Descritores: Anormalidades congênitas; Recém-nascidos; Mortalidade infantil; Enfermagem neonatal.

Objective: to analyze the relationship between knowledge and the adequacy of nursing annotations and their determinants. Method: An exploratory, descriptive and quantitative approach, carried out in the Medical Clinic and in the Adult Intensive Care Unit of a Brazilian university hospital. A total of 114 professionals and 41 medical records were included. Results: The professionals had a high mean score of knowledge and a low mean score of adequacy and there was no correlation between them (rs = -0,122; p > 0.05). The knowledge score was higher for professionals graduated in Nursing. The mean score of adequacy was higher for the professional category nurse if packed in Medical Clinic and with the professional that was dissatisfied with the training. Conclusion: there is no relationship between the professional's knowledge about nursing notes and the adequacy of the notes, which leads to serious ethical, legal and patient safety issues.

AimsWe aimed to assess the accessibility and informativeness of the content of daily nursing notes through an audit, and improve deficiencies identified.BackgroundNursing notes are an important source of observation findings, of in-ward psychiatry patients.There can be variations in the quality of the notes as well as information contained within.A basic level of clarity and information within all notes will be helpful in using these to inform the management of patients.MethodAn audit was carried-out in a ward treating working-age patients for psychiatric illnesses.Setting standards - standard required of a daily progress note was decided after discussion in multi-disciplinary team meeting (MDT). Clear language and information on; mental-state, medication, meals, physical health, personal care, activities, risks and use of leave, were identified as requirements.Retrospective audit - First audit cycle was carried-out by assessing the notes two weeks retrospectively. The assessment instrument used a qualitative measurement of the readability of the notes as well as quantitative assessment of the contents.Intervention - The standards set during the MDT, as well as a suggested format for recording notes, were communicated to the staff through email. Follow-up meetings with individual staff members and MDT, to evaluate staff satisfaction and new suggestions to improve the format were held. Difficulties staff encountered when implementing the format were discussed and resolved.Second audit cycle - Following implementation of the intervention, the notes were again assessed using the same instrument.ConclusionDifficulty in accessing information from the notes was noted in the first audit cycle. The average score for accessibility of information when scored on Likert scale + 3 to -3, was 1. Use of language scored 2 on average. On the second audit cycle, accessibility had increased to 3 on average while language score remained 2.Quantitative measurement was done for presence of information on; mental state, medication, meals, physical health, personal care, activities, risks and use of time away from ward. All of these parameters showed an increase in the post-intervention second audit cycle. Information on taking meals, medication, and physical health was present 100% of the time in the second cycle. Most improvement was in information on personal care which showed a five-fold increase, from 17% to 89%In conclusion, standard for nursing notes arrived via discussion and consensus in MDT, has been successful in improving the accessibility and information within nursing notes.

PURPOSE This study explored how well the Nursing Interventions Classification (NIC) covers adult inpatient psychiatric care. METHODS By systematic analyses and a mapping approach, documented nursing interventions were assessed on concurrencies with the NIC. FINDINGS From 2,153 intervention descriptions in nursing notes, 1,924 were recognizable as NIC interventions, and 229 did not match the NIC. 89.4% of all identified descriptions of interventions were recognizable as NIC interventions on the level of definition. CONCLUSIONS This study demonstrates that the NIC describes adult inpatient psychiatric care to a large extent. Nevertheless, further development of the classification is important. PRACTICE IMPLICATIONS The study results provide a basis for further developing the NIC and to reinforce its use in inpatient psychiatric settings.

Background Nursing notes have not been widely used in prediction models for clinical outcomes, despite containing rich information. Advances in natural language processing have made it possible to extract information from large scale unstructured data like nursing notes. This study extracted the sentiment—impressions and attitudes—of nurses, and examined how sentiment relates to 30-day mortality and survival. Methods This study applied a sentiment analysis algorithm to nursing notes extracted from MIMIC-III, a public intensive care unit (ICU) database. A multiple logistic regression model was fitted to the data to correlate measured sentiment with 30-day mortality while controlling for gender, type of ICU, and SAPS-II score. The association between measured sentiment and 30-day mortality was further examined in assessing the predictive performance of sentiment score as a feature in a classifier, and in a survival analysis for different levels of measured sentiment. Results Nursing notes from 27,477 ICU patients, with an overall 30-day mortality of 11.02%, were extracted. In the presence of known predictors of 30-day mortality, mean sentiment polarity was a highly significant predictor in a multiple logistic regression model (Adjusted OR = 0.4626, p < 0.001, 95% CI: [0.4244, 0.5041]) and led to improved predictive accuracy (AUROC = 0.8189 versus 0.8092, 95% BCI of difference: [0.0070, 0.0126]). The Kaplan Meier survival curves showed that mean sentiment polarity quartiles are positively correlated with patient survival (log-rank test: p < 0.001). Conclusions This study showed that quantitative measures of unstructured clinical notes, such as sentiment of clinicians, correlate with 30-day mortality and survival, thus can also serve as a predictor of patient outcomes in the ICU. Therefore, further research is warranted to study and make use of the wealth of data that clinical notes have to offer.

Objective: To verify if the nursing notes improved before and after a training of short duration and the factors those determine this change. Method: We analyzed 1551 reports/nursing notes in two inpatient units and two intensive care units. There was used a form in which there were recorded the adequacies or otherwise of the annotations in function of: the course, shift, professional category, and days of hospitalization of the patient. Results: We observed that there was improvement in the records made after the training course, with an increase of the adequacies. The intensive therapy units showed higher scores for appropriateness to the wards. The time of hospitalization of the patient eventually influences the scores of adequacies. The score of appropriateness of annotations was not different between the professional categories. Conclusion: The action of training of short duration was effective in improving the nursing notes, strengthening the role of continuous education in health services.

Agitation is one of the most common words to be found in nursing notes, however, it is ill-defined. This article describes the various causes of agitation, both physical and mental, and describes the common consequences. The importance of the recently published NICE guidance on violence and aggression is emphasised, with a recommendation that this should be required reading for mental health nurses.

Severe sepsis and septic shock are conditions that affect millions of patients and have close to 50% mortality rate. Early identification of at-risk patients significantly improves outcomes. Electronic surveillance tools have been developed to monitor structured Electronic Medical Records and automatically recognize early signs of sepsis. However, many sepsis risk factors (e.g. symptoms and signs of infection) are often captured only in free text clinical notes. In this study, we developed a method for automatic monitoring of nursing notes for signs and symptoms of infection. We utilized a creative approach to automatically generate an annotated dataset. The dataset was used to create a Machine Learning model that achieved an F1-score ranging from 79 to 96%., Comment: BioNLP 2017 (2017): 257-262

We present our initial evaluation of a prototype system designed to assist nurses in assigning subject headings to nursing narratives – written in the context of documenting patient care in hospitals. Currently nurses may need to memorize several hundred subject headings from standardized nursing terminologies when structuring and assigning the right section/subject headings to their text. Our aim is to allow nurses to write in a narrative manner without having to plan and structure the text with respect to sections and subject headings, instead the system should assist with the assignment of subject headings and restructuring afterwards. We hypothesize that this could reduce the time and effort needed for nursing documentation in hospitals. A central component of the system is a text classification model based on a long short-term memory (LSTM) recurrent neural network architecture, trained on a large data set of nursing notes. A simple Web-based interface has been implemented for user interaction. To evaluate the system, three nurses write a set of artificial nursing shift notes in a fully unstructured narrative manner, without planning for or consider the use of sections and subject headings. These are then fed to the system which assigns subject headings to each sentence and then groups them into paragraphs. Manual evaluation is conducted by a group of nurses. The results show that about 70% of the sentences are assigned to correct subject headings. The nurses believe that such a system can be of great help in making nursing documentation in hospitals easier and less time consuming. Finally, various measures and approaches for improving the system are discussed.

Trastuzumab (Herceptin) is used in neoadjuvant, adjuvant and metastatic breast cancer. Infusion reactions are a common side effect most of which are mild and easily managed, anaphylaxis occurs rarely. The summary of product characteristics recommends observation for 6 hours after the commencement of the first administration; we wanted to evaluate this practice. We assessed first administrations of trastuzumab infusions retrospectively to determine both rate and timing of reactions. Medical and nursing notes of 94 patients who had been prescribed intravenous trastuzumab in 2012 were reviewed; 2 additional patients did not have records available. Fourteen patients received palliative, 73 adjuvant and 7 neoadjuvant trastuzumab.r. Two (2%) had a reaction to trastuzumab occurring at 70 and 80 min from infusion commencement. We did not observe a reaction in the 4.5 hours after the 90 min infusion was complete. We recommend discharge with verbal and written advice immediately after uncomplicated first administration.

Objectives: In this paper, we study the development and domain-adaptation of statistical syntactic parsers for three different clinical domains in Finnish. Methods and materials: The materials include text from daily nursing notes written by nurses in an intensive care unit, physicians' notes from cardiology patients' health records, and daily nursing notes from cardiology patients' health records. The parsing is performed with the statistical parser of Bohnet (http://code.google.com/p/mate-tools/, accessed: 22 November 2013). Results: A parser trained only on general language performs poorly in all clinical subdomains, the labelled attachment score (LAS) ranging from 59.4% to 71.4%, whereas domain data combined with general language gives better results, the LAS varying between 67.2% and 81.7%. However, even a small amount of clinical domain data quickly outperforms this and also clinical data from other domains is more beneficial (LAS 71.3-80.0%) than general language only. The best results (LAS 77.4-84.6%) are achieved by using as training data the combination of all the clinical treebanks. Conclusions: In order to develop a good syntactic parser for clinical language variants, a general language resource is not mandatory, while data from clinical fields is. However, in addition to the exact same clinical domain, also data from other clinical domains is useful.

This was a retrospective cross-sectional study of 100 emergency department positive influenza-like illness (ILI) patients at an academic medical center to investigate which section(s) of a patient's electronic medical record (EMR) contains the most relevant information for timely detection of ILI. The history of present illness and review of systems, followed by the nursing notes sections of the EMR were information rich and the most relevant sections for ILI surveillance for the study site.

Pesquisa qualitativa descritiva retrospectiva objetivou descrever como a Enfermagem maneja a dor na criança com câncer. Os dados foram coletados nos prontuários de crianças internadas em uma unidade especializada no tratamento do câncer de um hospital de ensino do Sul do Brasil entre maio e junho de 2008. Os dados quantitativos foram submetidos à análise descritiva e os registros de enfermagem foram organizados em um quadro sinóptico ao qual foi aplicada a análise temática. Os resultados mostraram que 47,27% das crianças apresentavam queixas de dor. O tratamento medicamentoso foi o principal para toda e qualquer manifestação de choro; métodos menos invasivos e/ou estratégias alternativas de manejo foram raros. Conclui-se que há necessidade de se estabelecer métodos de avaliação e manejo da dor, conforme a faixa etária e o nível de desenvolvimento da criança e realizar registros de enfermagem com atenção, aliando o conhecimento técnico-científico à sensibilidade e afetividade. This qualitative, descriptive, retrospective research aimed to describe how Nursing manages pain in children with cancer. The data were collected from the hospital notes of children hospitalised in a unit specialising in the treatment of cancer in a teaching hospital in South Brazil between May and June 2008. The quantitative data were submitted to descriptive analysis and the nursing notes were organised in a synoptic chart to which thematic analysis was applied. The results showed that 47.27% of children presented complaints of pain. Treatment with medicines was the principal response to all and any manifestations of crying; less invasive, or alternative strategies of pain management were rare. It was concluded that there is a need to establish methods for assessment and management of pain, according to the age group and level of development of the child, and to keep nursing notes with attention, allying technical-scientific knowledge with sensitivity and affection. Investigación cualitativa descriptiva retrospectiva cuyo objetivo fue describir como la Enfermería maneja el dolor en niño con cáncer. Los datos fueron recogidos en los prontuarios de los niños internados en una unidad especializada en tratamiento de cáncer de un hospital de enseñanza del Sur de Brasil entre mayo y junio de 2008. Los datos cuantitativos fueron sometidos al análisis descriptivo y los registros de enfermería fueron organizados en un cuadro sinóptico al cual fue aplicado el análisis temático. Los resultados revelaron que 47,27% de los niños presentaban quejas de dolor. El tratamiento medicamentoso fue el principal para toda y cualquier manifestación de lloro; métodos menos invasivos y/o estrategias alternativas de manejo fueron raros. Se concluye que hay necesidad de establecerse métodos de evaluación y manejo del dolor, de acuerdo a la franja etaria y el nivel de desarrollo del niño y realizar registros de enfermería con antención, uniendo el conocimiento técnico-científico a la sensibilidad y afectividad.

Binary classification based methods are commonly used for designing predictive models in healthcare. A common problem in many healthcare datasets is that of imbalance, where there are far more observations in one class than the other during training. In such conditions, most classifiers do not have good predictive accuracy with respect to the under-represented class. We design a new similarity-based classifier to learn from imbalanced datasets, wherein input features are transformed using similarity with respect to a chosen subset of training points. We empirically demonstrate the superiority of our algorithm over state-of-the-art methods for imbalanced data classification in real and synthetic datasets. We also illustrate the application of our classifier in predicting Acute Respiratory Failure (ARF), a critical complication in Intensive Care Units (ICU), using semi-structured text contained in nursing notes recorded during a patient's ICU stay. Our experiments, on more than 800 patient records show that using our new classifier to learn from text- based features can effectively be used to predict ARF and, potentially, other complications in ICUs.

Accurate mortality prediction is an important task in intensive care units in order to channel prompt care to patients in the most critical condition and to reduce nurses' alarm fatigue. Nursing notes carry valuable information in this regard, but nothing has been reported about the effectiveness of temporal analysis of nursing notes in mortality prediction tasks. We propose a time series model that uncovers the temporal dynamics of patients' underlying states from nursing notes. The effectiveness of this information in mortality prediction is examined for mortality prediction for five different time spans ranging from one day to one year. Our experiments show that the model captures both patient states and their temporal dynamics that have a strong correlation with patient mortality. The results also show that incorporating temporal information improves performance in long-term mortality prediction, but has no significant effect in short-term prediction.

In an interdisciplinary collaboration between the Computer & Information Technology (CIT) and Nursing (NSG) Departments at the Middletown and Hamilton regional campuses of Miami University (of Ohio), student team members created a Web-based application to create Electronic Nursing Notes. Students from the two departments worked together to design and develop the application, which will be used by the Nursing Department to teach their students. The NSG students were the customers and provided samples of a paper-based system currently used by the hospital where the nurses worked. From those samples, and with much interaction with the NSG students, the CIT students created the Electronic Nursing Notes application. In this article, we describe the project and present reactions from both the student team members and also the faculty team members.

The purpose of this survey was to improve nursing care of patients with peripheral intravenous catheters (PVCs), focusing on duration of cannulation. The survey was conducted in 20 general wards recording data on the duration of cannulation, site-infection, dating of PVC dressing and documentation in nursing notes. Nursing staff were interviewed on duration of the PVC and a documentation form was introduced during the survey. A total of 554 PVCs in 397 patients were surveyed. Duration of cannulation ranged from one to ten days, with 402 (73%) of PVCs removed by day three. The site-infection rate was 28 (5%) with no cases of blood stream infection. Most site infection (20 of 28 (71%)) occurred within the first three days. The duration of cannulation, from interview, was known by nurses in 416 (75%) of cases and documented in 208 (40%) of cases. Eighteen months after its introduction, the PVC documentation form was in use in 19 of 20 wards for 60 (76%) PVCs. While the infection rate was low and nurses were generally aware of the duration of cannulation, inadequate documentation by nursing and medical staff was a cause for concern. Information on PVCs should be included in standard documentation on all wards and in relevant departments to assist nurses and others in the provision of quality care to patients.

Aims: to identify the perception of nursing assistants working in a mixed unit about nursing notes. Method: qualitative study in a mixed unit of urgency and emergency in the south of Brazil. The technique of Bardin content analysis was employed for data analysis. Results: after the analysis, the following category emerged: nursing notes: communication among the nursing staff and its technical and legal aspects. As well as the subcategories: nursing notes as communication links among the multidisciplinary team, legal and scientific aspects of nursing notes, technical aspects related to the nursing annotation. Final considerations: it was concluded that there is awareness of the importance of nursing notes. However, this practice faces challenges that hinder effective records, mainly when the written formalization of the work is forgotten.

Postoperative Acute Respiratory Failure (ARF) is a serious complication in critical care affecting patient morbidity and mortality. In this paper we investigate a novel approach to predicting ARF in critically ill patients. We study the use of two disparate sources of information – semi-structured text contained in nursing notes and investigative reports that are regularly recorded and the respiration rate, a physiological signal that is continuously monitored during a patient's ICU stay. Unlike previous works that retrospectively analyze complications, we exclude discharge summaries from our analysis envisaging a real time system that predicts ARF during the ICU stay. Our experiments, on more than 800 patient records from the MIMIC II database, demonstrate that text sources within the ICU contain strong signals for distinguishing between patients who are at risk for ARF from those who are not at risk. These results suggest that large scale systems using both structured and unstructured data recorded in critical care can be effectively used to predict complications, which in turn can lead to preemptive care with potentially improved outcomes, mortality rates and decreased length of stay and cost.

Estudo retrospectivo no qual foram analisadas as anotações de enfermagem em uma Unidade Especializada que desenvolve o cuidado ao paciente embasado no Processo de Enfermagem. Os dados foram coletados em dois prontuários, utilizando-se instrumento construído para esta finalidade. Na análise, considerou-se, aspectos que avaliaram aparência e conteúdo dos registros. Nos resultados, o auxiliar de enfermagem destacou-se pelo maior número de anotações extensas e pouco específicas, já nos registros realizados pelo enfermeiro observou-se maior número de anotações legíveis e objetivas. Por expressar o trabalho da Enfermagem, maiores investimentos devem ser feitos para tornar as anotações de enfermagem mais objetivas e completas. This is a retrospective study that analyzed the nursing notations in a Specialized Unit which develops the care to the patient based on Nursing Process. The data were collected through two promptuaries utilizing instrument constructed for this purpose. Aspects which valuate appearance and content were considered in the analysis. The nursing assistant was distinguished in the results considering the bigger number of extensive and not very specific notations, and in the registrations achieved by the nurse, it was observed a bigger number of legible and objective notations. By expressing the Nursing work, greater investments must be made to become more objective and full the nursing notations. Estudio retrospectivo en el cual furaon analizados las anotaciones de enfermería en una Unidad Especializada que desarrolla el cuidado al paciente baseado en el Proceso de Enfermería. Los datos fueron colectados en dos historias clínicas utilizandose instrumento construido para esta finalidad. En el análisis fueron considerados aspectos que evaluaron la apariencia y el contenido de los registros. En los resultados el auxiliar de enfermería se destacó por el mayor número de anotaciones de características extensas y poco específicas. En los registros realizados por el enfermero se observó mayor número de anotaciones legibles y objetivas. Por expresar el trabajo de Enfermería, mayores inversiones deben ser realizadas para tornar las anotaciones de enfermería más completas y objetivas.

Despite a long-standing interest within applied linguistics in the analysis of written genres, few studies have attempted to show how such genres are appropriated by new members in academic or workplace settings. Based on a 22-month qualitative study, this article reports on how francophone nurses, who were newly hired in an English-medium hospital in Montreal, Canada, developed skill in writing nursing notes (which differed from the way they were done in French) in English. Central to the analysis is the construct of mediation, explored in terms of how collaborative processes, both overt and covert, shape text production as well as other less visible, taken-for-granted aspects of the social context.

An audit of case notes and a survey of in-patients was carried out to evaluate risk assessment on an in-patient ward. We found considerable inconsistencies between the risk assessment records in medical and nursing notes. A systematic survey found higher levels of risk than either set of notes, but combining the notes improved the quality of risk assessment compared to the survey. We suggest three key areas for action to improve risk assessment.