Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care

Abstract

Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them. We conducted 10 observations of home care agency admissions with five admission nurses in rural Pennsylvania. We collected screenshots and recorded the admission process. We asked the nurses questions outside the point of care. We coded the nurses' strategies at the data-entry screen level. Using thematic analysis, we investigated the influence of nursing goals on documentation strategies. Subject matter experts reviewed our findings. Several goals affect nurses' documentation strategies: ensure data accuracy, reduce time in the patient's home, and prevent infection. Home care admission nurses distribute the electronic documentation temporally due to their goals. Nurses developed memory aids to support completion of the documentation after leaving the patients' homes. Design and training should support the distributed manner in which home care nurses document patient encounters.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Home Healthcare Clinicians’ Perspectives on Electronic Health Records: A Qualitative Study

“…Start of care documentation, completed at patient's admission to HHC, was specifically noted as being more time consuming compared to documenting other care activities. This can cause a delay in the initiation of patient care at the point of care [19] indicating the importance of streamlined, efficient EHRs.…”

Evaluation of nursing documentation: The experience of nurses from the primary and secondary/tertiary health care

“…An electronic medical record supports some of those goals, including high-quality documentation; however, nurses sometimes cannot complete the documentation at the place of providing health care -at patient's home. Yang et al made 10 observations to estimate the impact of the importance of health care goals on keeping records in the nursing documentation (27).…”

Barriers and Benefits of Information Communication Technologies Used by Health Care Aides

“…We classified the selected studies in five groups, according to the main purpose of ICT use by health care aides: (1) improve everyday work (n ¼ 12, 30%), 46,[51][52][53][54][55][56][57][58][59][60][61] (2) access electronic health records for home care (n ¼ 9, 22.5%), [62][63][64][65][66][67][68][69][70] (3) facilitate client assessment and care planning (n ¼ 9, 22.5%), [71][72][73][74][75][76][77][78][79] (4) enhance communication (n ¼ 7, 17.5%), 2,40,80-83 and (5) provide care remotely (n ¼ 3, 7.5%). 35,84,85 Fig.…”