Nursing record systems: effects on nursing practice and healthcare outcomes

Urquhart, Christine; Currell, Rosemary; Grant, Maria J.; Hardiker, Nicholas R.

doi:10.1002/14651858.cd002099.pub2

Cited by 135 publications

(142 citation statements)

References 38 publications

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“…Another study of a computer-based nursing documentation system in 4 hospital wards showed similar improvements in nursing documentation [51]. However, the use of information and communication systems to increase the quality of nursing documentation has shown mixed results [20,51,52]. A study from a hospital setting showed that nurses only recorded 40% of what they actually provided for patients [53].…”

Section: Discussionmentioning

confidence: 99%

“…In addition, the standardized format of the EHR documents for care planning may have had an impact on what nurses documented, which may have influenced the results. In a systematic review by Urquhart and colleagues [52], EHRs designed for specific problems were successful, but EHRs did not necessarily lead to improvements in general nursing practice.…”

Section: Limitations and Methodological Considerationsmentioning

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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Section: Discussionmentioning

confidence: 99%

Section: Limitations and Methodological Considerationsmentioning

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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“…Nursing records are more than the records of care which is planned and given to individual residents [41]. They can be the evidence used for quality assurance, legal purposes, health planning, allocation of resources and nursing development and research [42].…”

Section: Improved Quality Of Nursing Documentationmentioning

confidence: 99%

“…Urquhart et al [41], cited in Oroviogoicoechea et al's review [43], suggested quality of health care is directly related to the quality of information available to healthcare workers thus information management is an essential part of health care delivery. The interviewees' documentation time was perceived to be reduced, allowing staff to spend more time with residents, it is the same as Chau and…”

Section: The Benefits To the Residentsmentioning

confidence: 99%

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

Zhang

Shen

2012

International Journal of Medical Informatics

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Purpose: Information and communications technology solutions have been introduced into the residential aged care system in order to improve the effectiveness and efficiency of aged care, however to date, the actual benefits have not been systematically analysed. The aim of this study was to identify the benefits of electronic health records (EHR) in residential aged care services and to examine how the benefits have been achieved. Method: A qualitative interview study was conducted in nine residential aged care facilities (RACFs) belonging to three organisations in the Australian Capital Territory (ACT), New South Wales (NSW) and Queensland, Australia. A longitudinal investigation after the implementation of the aged care EHR systems was conducted at two data points: January 2009 to December 2009 and December 2010 to February 2011. Semi-structured interviews were conducted with 110 care staff members selected through theoretical sampling, representing all levels of care staff who worked in those facilities. Results: Three categories of benefits were perceived by the care staff members according to who gain the benefits: the benefits to individual care staff members, to residents and to the RACFs. The benefits to individual care staff members include an improvement of documentation efficiency, information and knowledge growth as well as empowering the staff; the benefits to residents are an improvement in the quality of individual residents' health records, the higher quality of care and smoother communication between the residents and aged care staff; the RACFs gain an increased ability to manage information and acquire funding, an increase in their ability to control the care quality and improvements in the working environment and educational benefits. Three factors leading to these benefits were examined: the nature of the aged care EHR systems in comparison with paper-based records; the way the systems were used by the staff and one benefit that could lead to another. Conclusions: In this study, EHR systems were perceived to have substantial benefits for care staff, residents and the aged care organisations introducing the systems. The benefits were derived from the nature of the aged care EHR systems, staff members' continuous use of the systems, and one benefit led to the other. -2 - AbstractPurpose: Information and communications technology solutions have been introduced into the residential

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“…Dersom pasientinformasjon ikke blir nøye registrert og dokumentert, øker sjansen for at pasientene blir utsatt for ubehag og/eller feil (14,19).…”

Section: Må Ha Nok Begreperunclassified

Felles fagspråk i sykepleie=dokumentasjon

Laukvik¹,

Mølstad²,

Fossum³

2017

Sykepleien

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Nursing record systems: effects on nursing practice and healthcare outcomes

Cited by 135 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

The benefits of introducing electronic health records in residential aged care facilities: A multiple case study

Felles fagspråk i sykepleie=dokumentasjon

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