Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals

Shala, Danielle Ritz; Jones, Aaron; Fairbrother, Greg; Tran, Duc A.

doi:10.1016/j.ijmedinf.2021.104603

Cited by 5 publications

(4 citation statements)

References 26 publications

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“…In a separate analysis of inpatient encounters, 78% ( n = 22 953) of AAA forms were completed within the first 24 h of admission, 13.3% ( n = 3910) between 24 and 72 h from admission, and 8.7% ( n = 2558) beyond 72 h from admission. 11 …”

Section: Resultsmentioning

confidence: 99%

“…The benefit of completing the form in the middle, or toward the end of a patient’s stay is questionable and could suggest that the form may have been completed for administrative reasons rather than for patient care. 11 This is counter to the principal purpose of nursing admission assessment and highlights a need for further education on the importance of timely documentation of patient assessment.…”

Section: Discussionmentioning

confidence: 99%

“…The timeliness of AAA form completion was determined in a separate analysis of adult inpatient admissions ( n = 37 512) and calculated as the interval between date and time of admission and form completion. 11 …”

Section: Methodsmentioning

confidence: 99%

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Adopting an American framework to optimize nursing admission documentation in an Australian health organization

et al. 2022

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Objective Apply and modify the American Essential Clinical Dataset (ECD) approach to optimize the data elements of an electronic nursing admission assessment form in a metropolitan Australian local health district. Materials and Methods We used the American ECD approach but made modifications. Our approach included (1) a review of data, (2) a review of current admission practice via consultations with nurses, (3) a review of evidence and policies, (4) workshops with nursing and informatics teams in partnership with the electronic medical record (eMR) vendor, and (5) team debrief sessions to consolidate findings and decide what data elements should be kept, moved, or removed from the admission form. Results Of 165 data elements in the form, 32% (n = 53) had 0% usage, while 25% (n = 43) had 100% usage. Nurses’ perceptions of the form’s purpose varied. Eight policy documents specifically prescribed data to be noted at admission. Workshops revealed risks of moving or removing data elements, but also uncovered ways of streamlining the form. Consolidation of findings from all phases resulted in a recommendation to reduce 91% of data elements. Discussion Application of a modified ECD approach allowed the team to identify opportunities for significantly reducing and reorganizing data elements in the eMR to enhance the utility, quality, visibility, and value of nursing admission data. Conclusion We found the modified ECD approach effective for identifying data elements and work processes that were unnecessary and duplicated. Our findings and methodology can inform improvements in nursing clinical practice, information management, and governance in a digital health age.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Adopting an American framework to optimize nursing admission documentation in an Australian health organization

et al. 2022

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“…Dokumentasi keperawatan penting karena dapat memberikan informasi yang relevan dan merencanakan perawatan pasien yang sesuai. Dokumentasi yang dilakukan dengan tepat dapat berdampak pada pemberian layanan yang efisien dan berkualitas tinggi serta pengambilan keputusan dari pemberian terapi medis dan tim multidisiplin ilmu lainnya berdasarkan catatan klinis terkini yang telah dibuat oleh perawat di setiap shift (Shala et al, 2021).…”

Section: Pembahasanunclassified

Optimalisasi Tele-Supervisi dalam Pendokumentasian Asuhan Keperawatan di Ruang Rawat Inap Rumah Sakit: Suatu Program Inovasi

Alfisah

Hariyati²,

Dewi³

2022

JOTING

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This study aims to encourage and improve the quality of nursing care through an innovation program in optimizing supervision in the documentation of nursing care. The method used is an innovation program with a pilot study through a problem solving approach. The innovation program was carried out on the head of the room and team leader who were recruited through purposive sampling using questionnaires, observation sheets and interviews. The results showed that: 1) the problem identification stage, need improvement in the quality of nursing care documentation; 2) the implementation stage, it is necessary to develop a nursing care guide, a checklist form for the quality of documentation, socialization, mentoring and testing of Tele-Supervision; 3) the evaluation stage, the results of the supervision of the documentation of nursing care have been carried out perfectly and completely by the implementing nurse through a trial of the Tele-Supervision form. In conclusion, improving the quality of nursing care documentation needs to be controlled with the implementation of scheduled supervision by the head of the room. Keywords: Nursing Care, Nursing Documentation, Innovation, Tele-Supervision

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Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program

et al. 2022

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Background Introducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite “big-bang” EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care. Objective Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation. Methods The Model for Improvement quality improvement framework guided cycles of “Plan, Do, Study, Act.” Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps. Results Analysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance. Conclusion This work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.

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Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals

Cited by 5 publications

References 26 publications

Adopting an American framework to optimize nursing admission documentation in an Australian health organization

Adopting an American framework to optimize nursing admission documentation in an Australian health organization

Optimalisasi Tele-Supervisi dalam Pendokumentasian Asuhan Keperawatan di Ruang Rawat Inap Rumah Sakit: Suatu Program Inovasi

Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program

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