Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care

Gunningberg, Lena; Fogelberg-Dahm, Marie; Ehrenberg, Anna

doi:10.1111/j.1365-2702.2008.02647.x

Cited by 71 publications

(66 citation statements)

References 20 publications

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“…This fact contrasts with an investigation on the completeness of PU records in the electronic medical record that indicated that 73% of nurses did not use standardized language and documented the nurses' interventions in free text (26) . According to the authors, standardized expressions were imprecise and moved away from the language commonly used by nurses.…”

Section: Completenessmentioning

confidence: 63%

“…In contrast, in the other events, follow-up care was recorded at a higher percentage compared with recording health problems of both SSIs (86.3%) and AP (79.7%). On the other hand, when nurses must provide specific descriptions, such as characteristics of the injured tissue or the exudate, they use free text more often (26) . This situation in our research is not only limited to PU events but also SSIs.…”

Section: Completenessmentioning

confidence: 99%

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Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

González-Samartino

Delgado‐Hito

Adamuz-Tomás

et al. 2018

Rev. esc. enferm. USP

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Objective:To determine what adverse events, including pressure ulcers, infection of the surgical site and aspiration pneumonia, nurses record in clinical histories, in terms of diagnostic accuracy and completeness, through ATIC. Method: Observational, descriptive, cross-sectional, multicenter study of 64 medical-surgical and semi-critical units of two university hospitals in Catalonia, Spain, during 2015. The diagnostic accuracy was assessed by means of the correspondence between the event declared in the Minimum Basic Data Set and the problem documented by the nurse. The record was considered complete when it contained the risk of the event, prescriptions of care and a record of the evolution. Results: The sample evaluated included 459 records. The accuracy results of pressure ulcers are highly correlated between the nursing diagnosis recorded and that declared in the Minimum Basic Data Set. The accuracy in surgical site infection is moderate, and aspiration resulting in pneumonia is very low. The completeness of results is remarkable, except for the risk of bronchoaspiration. Conclusion: The adverse event recorded by nurses with greatest accuracy is pressure ulcers.

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Section: Completenessmentioning

confidence: 63%

Section: Completenessmentioning

confidence: 99%

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

González-Samartino

Delgado‐Hito

Adamuz-Tomás

et al. 2018

Rev. esc. enferm. USP

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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%

“…A structured format for recording has been effective at increasing the quality of nursing documentation [39,49]. A study conducted in a Swedish hospital showed that both the quality and comprehensiveness of PU documentation significantly improved after implementing an EHR system with pre-formulated templates [39]; however, the study had a before-after design with no control group.…”

Section: Discussionmentioning

confidence: 99%

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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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A Case–Control Study of Pediatric Falls Using Electronic Medical Records

Messmer

Williams

2013

Rehabilitation Nursing

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The purpose of this study was to retrospectively review Humpty Dumpty Falls Scale (HDFS) scores using electronic medical records (EMR) reports at a pediatric hospital to determine characteristics related to falls, injuries, and performance of the HDFS tool. The specific research question was: Is there a significant difference in HDFS total scores between cases (children who fell) and controls (those who did not fall)? Results from 74 cases and 242 controls revealed the number of falls did not differ significantly between those who obtained high HDFS scores and those who obtained low scores. HDFS sensitivity was 57%, specificity was 39%. The pediatric patients who fell were mostly oriented and ambulating; falls with injury did not exceed 19%. Future case-control studies should use larger sample sizes across multiple institutions with EMR capability.

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Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care

Abstract: Education related to the use of the electronic health record and evidence-based pressure ulcer prevention should be provided to the nurses. To facilitate documentation, the templates need to be refined to be more user-friendly.

Cited by 71 publications

References 20 publications

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

Precisión y exhaustividad del registro de eventos adversos mediante una terminología de interfase

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

A Case–Control Study of Pediatric Falls Using Electronic Medical Records

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