Advancing nursing documentation—An intervention study using patients with leg ulcer as an example

Törnvall, Eva; Wahren, Lis Karin; Wilhelmsson, Susan

doi:10.1016/j.ijmedinf.2009.04.002

Cited by 30 publications

(38 citation statements)

References 38 publications

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“…To the best of our knowledge, no other studies in nursing homes have shown the effects of using a CDSS on the completeness and comprehensiveness of nursing documentation, though several studies have shown improved documentation after educational interventions in paper-based [40,47] and electronic health records [39,48].…”

Section: Discussionmentioning

confidence: 99%

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Fossum

Ehnfors

Svensson

et al. 2013

International Journal of Medical Informatics

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Background: Nursing documentation is essential for facilitating the flow of information to guarantee continuity, quality and safety in care. High-quality nursing documentation is frequently lacking; the implementation of computerized decision support systems is expected to improve clinical practice and nursing documentation. Aim:The present study aimed at investigate the effects of a computerized decision support system and an educational program as intervention strategies for improved nursing documentation practice on pressure ulcers and malnutrition in nursing homes.Design, setting and participants: An intervention study with two intervention groups and one control group was used. Fifteen nursing homes in southern Norway were included. A convenience sample of electronic healthcare records from 46 units was included. Inclusion criteria were records with presence of pressure ulcers and/or malnutrition. The residents were assessed before and after an intervention of a computerized decision support system in the electronic healthcare records. Data were collected through a review of 150 records before (2007) Methods:The nurses in intervention group 1 were offered educational sessions and were trained to use the computerized decision support system, which they used for eight months in 2008 and 2009. The nurses in intervention group 2 were offered the same educational program but did not use the computerized decision support system. The nurses in the control group were not subject to any intervention. The resident records were examined for the completeness and comprehensiveness of the documentation of pressure ulcers and malnutrition with three data collection forms and the data were analyzed with non-parametric statistics. Results:The implementation of the computerized decision support system and the educational program resulted in a more complete and comprehensive documentation of pressure ulcer-and malnutrition-related nursing assessments and nursing interventions. Conclusion:This study provides evidence that the computerized decision support system and an educational program as implementation strategies had a positive influence on nursing documentation practice.Key words: decision support system, documentation, intervention studies, malnutrition, nursing audit, pressure ulcer. Highlights A computerized decision support system and an educational program were implemented. The computerized decision support system provided evidence-based interventions. The implementation resulted in a more complete and comprehensive documentation. The total number of documented nursing problems was relatively low.

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Section: Discussionmentioning

confidence: 99%

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Fossum

Ehnfors

Svensson

et al. 2013

International Journal of Medical Informatics

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“…What is often missed is the impact that the design of the display and information presented have on workflow. Nurses' use of HIT and the specific issues raised by nursing practice have become even more important as EMR implementations have struggled [20,21] to be successful. Our finding that nurses were not able to capitalize on the information available to them because of the lack of usability of the interface is similar to the work of Michel-Verkerke [8].…”

Section: Discussionmentioning

confidence: 99%

Use of a human factors approach to uncover informatics needs of nurses in documentation of care

Rogers

Sockolow

Bowles

et al. 2013

International Journal of Medical Informatics

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“…[16][17][18][19][20][21]23,24,31 This project did show promising results for using evidence-based flowsheets based on five of six stroke management goals, whereas the use of clinical decision support revealed insignificant results due to notable limitations. The impact of evidence-based nursing documentation flowsheets and clinical decision support reminders should continue to be measured for influence on the quality of nursing documentation and ultimately improve patient outcomes.…”

Section: Resultsmentioning

confidence: 99%

“…13,[15][16][17][18] Structured documentation templates for capturing data have also been shown to improve overall data quality by producing nursing documentation that is more complete, relevant, and comprehensive. [19][20][21] Several studies have evaluated the effectiveness of computerized documentation templates, merged with disease-specific content, to help standardize clinician documentation. 18,[21][22][23][24] Thus, documentation of disease-specific content for stroke may improve with the use of evidence-based content.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of Nursing Documentation Completion of Stroke Patients in the Emergency Department

Richardson

Sengstack

Doucette

et al. 2016

CIN: Computers, Informatics, Nursing

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The primary aim of this performance improvement project was to determine whether the electronic health record implementation of stroke-specific nursing documentation flowsheet templates and clinical decision support alerts improved the nursing documentation of eligible stroke patients in seven stroke-certified emergency departments. Two system enhancements were introduced into the electronic record in an effort to improve nursing documentation: disease-specific documentation flowsheets and clinical decision support alerts. Using a pre-post design, project measures included six stroke management goals as defined by the National Institute of Neurological Disorders and Stroke and three clinical decision support measures based on entry of orders used to trigger documentation reminders for nursing: (1) the National Institutes of Health's Stroke Scale, (2) neurological checks, and (3) dysphagia screening. Data were reviewed 6 months prior (n = 2293) and 6 months following the intervention (n = 2588). Fisher exact test was used for statistical analysis. Statistical significance was found for documentation of five of the six stroke management goals, although effect sizes were small. Customizing flowsheets to meet the needs of nursing workflow showed improvement in the completion of documentation. The effects of the decision support alerts on the completeness of nursing documentation were not statistically significant (likely due to lack of order entry). For example, an order for the National Institutes of Health Stroke Scale was entered only 10.7% of the time, which meant no alert would fire for nursing in the postintervention group. Future work should focus on decision support alerts that trigger reminders for clinicians to place relevant orders for this population.

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Advancing nursing documentation—An intervention study using patients with leg ulcer as an example

Cited by 30 publications

References 38 publications

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study

Use of a human factors approach to uncover informatics needs of nurses in documentation of care

Evaluation of Nursing Documentation Completion of Stroke Patients in the Emergency Department

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