Quality Documentation in the Electronic Medical Record

Scruth, Elizabeth; Soriano, Rayne

doi:10.1097/nur.0000000000000214

Cited by 2 publications

(1 citation statement)

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“…The use of copy and paste in electronic clinical note documentation has been widely acknowledged in health information technology studies (Bowman, 2013; Zhang et al, 2011). Clinicians use this functionality as it simplifies documentation, saves time and supports coding and regulatory requirements (Scruth & Soriano, 2016). In a survey of physicians from paediatric and medicine units in two large academic North American medical centres, 90% ( n = 226) of physicians used the copy‐paste functionality and 70% ( n = 177) used it almost always or most of the time when writing progress notes (O’Donnell et al, 2008).…”

Section: Introductionmentioning

confidence: 99%

Measuring text similarity and its associated factors in electronic nursing progress notes: A retrospective review

Shala

Sheppard‐Law

2022

Journal of Clinical Nursing

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Aims and objectives To measure text similarity in electronic nursing progress notes and determine factors associated with text similarity. Background Electronic clinical notes with redundant information masks clinically relevant information, increases clinicians’ cognitive burden and undermines patient safety. Design Retrospective review of electronic medical record nursing progress notes. Methods The study was conducted between November 2018 and February 2019 in two Australian Paediatric Intensive Care Units. De‐identified, randomly selected inpatient data were extracted from the network's database. Manually classified shift summary progress notes for each admission were sequenced from admission to discharge. Text similarity was calculated for consecutive pairs of nursing progress notes. Linear regression was undertaken to determine the association between the similarity scores and variables of interest: note word count, total number of notes and unit. The STROBE checklist was used for reporting. Results 921 shift summary nursing progress notes were analysed. Similarity scores were widely distributed with a median of 10.37%. Only 17.2% (n = 144) of the notes have similarity scores above 20%. Of these, 5% (n = 47) were above 50% similar in comparison with a previously written note. Similarity above 50% was observed as early as the first note pair in the course of a patient's admission. A significant difference was found between the similarity scores of Unit 1 and Unit 2. Hospital unit was the only variable of interest significantly associated with similarity scores. Conclusion Text similarity among electronic nursing progress notes in Australian Paediatric ICUs is minimal; however, notes with >50% similarity have been identified. Text analytics provides measurable data and insights about electronic clinical documentation to inform future nursing practice, research and eMR design. Relevance to clinical practice Findings have implications for nursing practice in the way that nursing staff are educated to maintain data quality, professional accountability and effective communication in electronic documentation and to avoid unnecessary repetition of text.

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Section: Introductionmentioning

confidence: 99%