Aim
To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation.
Design
Systematic review of systematic reviews.
Data sources
We ...systematically searched the databases PubMed and CINAHL for the period 2007–April 2017. We also performed additional searches.
Review methods
Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis.
Results
Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence‐based instruments were described for assessing the quality of nursing documentation, such as the D‐Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user‐friendliness and development in consultation with nursing staff.
Conclusion
Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important for high‐quality nursing documentation. The lack of evidence‐based quality indicators presents a challenge in the pursuit of high‐quality nursing documentation.
Impact
There is uncertainty in nursing practice about which criteria have to be met to achieve high‐quality documentation.
Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important.
These findings can help nursing staff and care organizations enhance the quality of nursing documentation.
摘要
目的
了解护理文件质量标准、编制工具和要求方面现有循证概况
设计
对系统评价进行系统综述
数据来源
我们系统地搜索了文献数据库和护理学数据库,搜索范围从2007年至2017年8月。我们还进行了其他搜索
综述方法
两位研究人员各自分步综述、评估所选综述方法的质量以及使用预定义的提取格式提取数据。我们进行了描述性综合分析。
结果
包括11项系统评价,从遵循护理程序和使用标准化的护理术语的重要性方面讲述几个质量标准。此外,还叙述了一些用于评估文件质量的循证工具如DCatch。而且发现电子护理文件的格式和系统的几个要求涉及到用户友好与护理人员协商发展的重要性。
结论
使文件与护理程序保持一致、使用标准术语、采用用户友好的格式和系统,这些对于建立高质量护理文件似乎非常重要。建立高质量文件的一大挑战即为缺乏循证的质量指标。
影响
在护理实践中,无法确定为建立高质量文件必须要满足哪些标准。
使文件与护理程序保持一致、使用标准术语、采用用户友好的格式和系统似乎很重要。
这些发现可以帮助护理人员和保健组织提高护理文件编制质量。
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
There was no significant improvement in the outcome measures of individual and overall order time for relevant recommendations (Figure 1, Table 1). The optimal proxy of study success is improved time ...to documentation and completeness of recommendations, which can mitigate communication errors during critical, post-procedure handoffs. Characteristics and Timing of Brief Operative Note Documentation and Relevant Orders Pre-Intervention (n=157) Post-Intervention (n=163) P-value Brief Operative Note Documentation First Note in Same Calendar Day 133/157 (85%) 161/163 (99%) < 0.001 Brief Operative Note Written 78/157 (50%) 148/163 (91%) < 0.001 First Note within 2 Hours of Procedure or by 5pm 103/157 (66%) 150/163 (92%) < 0.001 Median Time to Documentation (minutes) 113 31 < 0.001 Relevant Recommendations Addressed Diet 51/78 (65%) 145/148 (98%) < 0.001 Proton Pump Inhibitor 33/39 (85%) 78/85 (92%) 0.228 Anticoagulation 12/24 (50%) 38/42 (90%) < 0.001 Antiplatelets 4/21 (19%) 36/43 (84%) < 0.001 Note Addressed All Relevant Data 30/78 (38%) 133/148 (90%) < 0.001 Median Time to Implementation of Order (minutes) Diet 108 92 0.029 Proton Pump Inhibitor 86 191 < 0.001 Anticoagulation 151 260 0.239 Antiplatelets 144 241 0.966 Author Notes *Presenter
Code intelligence leverages machine learning techniques to extract knowledge from extensive code corpora, with the aim of developing intelligent tools to improve the quality and productivity of ...computer programming. Currently, there is already a thriving research community focusing on code intelligence, with efforts ranging from software engineering, machine learning, data mining, natural language processing, and programming languages. In this paper, we conduct a comprehensive literature review on deep learning for code intelligence, from the aspects of code representation learning, deep learning techniques, and application tasks. We also benchmark several state-of-the-art neural models for code intelligence, and provide an open-source toolkit tailored for the rapid prototyping of deep-learning-based code intelligence models. In particular, we inspect the existing code intelligence models under the basis of code representation learning, and provide a comprehensive overview to enhance comprehension of the present state of code intelligence. Furthermore, we publicly release the source code and data resources to provide the community with a ready-to-use benchmark, which can facilitate the evaluation and comparison of existing and future code intelligence models (https://xcodemind.github.io). At last, we also point out several challenging and promising directions for future research.
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IZUM, KILJ, NUK, PILJ, SAZU, UL, UM, UPUK
We are grateful to those who have provided the material for these reports. The online reporting form is available on the website (coress.org.uk), which also includes previous Feedback reports, and ...via the CORESS app. Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor's record of continuing professional development, or which may form part of appraisal or annual review of competence progression portfolio documentation. Trainee contributions are particularly welcome.
Through the study of the documentation from the Arquivo Histórico Ultramarino de Lisboa, this paper tries to understand the administrative process, the responsibilities and the importance of the ...royal control over the casting and recasting of Brazilian church bells, as a tool of direct control over the Brazilian Church and the development of territorial occupation. The documentation stands out the roll of the Conselho Ultramarino in the centralization of the kingdom’s bell casting, the weaknesses of this system, the general indifference on behalf of the royal power and the fragilities of the Brazilian church
This practice-based PhD project develops a ‘Sonic Ghosting' practice through a portfolio of compositions, installations and performances. Sonic Ghosting, as a mode of creative endeavor, offers a way ...to interrogate the relationship between space/place/memory and sound/music/noise by fracturing the soundscape of the present with the echoes, phantoms and potentialities of the soundscapes of the past/future. In one sense, it is ventriloquising the material/space/landscape that it engages with, extending it beyond the bounds of its normal sonic existence, and blurring the horizon between what is unheard/unseen but felt, and what is actually present. To achieve this, there is a creative and compositional employment of fracture, degradation and performance interruption – both temporally and spatially. Where sonic material is gleaned from on-site field recordings it is manipulated, cut-up, processed, delayed, moved in time and space. This process creates layers within the fabric of the work, between the memory of sound onsite, the recordings, their fractured remains, electronic and acoustic instrumentation, and the multiple modes of presentation and iteration: performance, installation, documentation, image, text. In some examples the resulting work is also presented in-situ alongside the soundscape of the place/space about which the work is made, or contextualised, with text/image/materials. The included portfolio contains documentation of a series of experimental works that explore a number of different creative modes, forms, and stimuli. These are: Chalk Pit, an installation and improvised performance interruption exploring the post-industrial landscape of the Sussex chalk industry; Ghosting the Periphery, a four channel presence-responsive installation exploring the gallery and peripheral spaces of the Hatton Gallery in Newcastle-upon-Tyne; Branch Lines, a composition and graphic score for Violin, Cello, Clarinet and Piano, exploring experiences of Causey Arch railway bridge in County Durham; Thrumming Halls, a movement/noise responsive installation presented binaurally, reflecting on the Barnsley National Union of Mineworkers Hall, inhabitants and spaces; Underdrift, an electroacoustic composition reflecting on the spaces around the Co-Operative Pioneer's Museum, Town Hall, and streets of Rochdale, Greater Manchester. In addition, the portfolio contains documentation of the final exhibition, Sonic Ghostings, presented at the Attenborough Centre for the Creative Arts, which incorporates the portfolio works alongside working materials, and brings the principles of a Sonic Ghosting practice to bear on the broader research project itself through a final composition: Fractures and Fragments. The accompanying commentary provides a critical and conceptual outline of a Sonic Ghosting practice, a reflective commentary on each of the portfolio works, and an overview of the experimental and creative research process undertaken over the course of the research project. It explores a range of relevant critical theory in order to consider how a Sonic Ghosting practice, and the specific portfolio works in question, interrogate the role of sound/music composition in exploring memory, space, place, ruin, landscape, hauntology and the spectral turn. It draws reference to a range of sources including key texts from sound and music studies (Salomé Voegelin, Sabine Vogel, Bennett Hogg, Anna Friz, Curtis Roads), cultural studies (Jacques Derrida, Fredrik Jameson, Michel de Certeau, Rebecca Solnit), and human geography (Tim Edensor, Nigel Thrift). The commentary also considers the artistic contexts of Sonic Ghosting, with a review of work by Jimi Hendrix, Robert van Heumen, and Chris Watson, as well as influences on specific works such as Kurt Schwitters, William Burroughs, Hildegard Westercamp, and John Cage.
Introduction:
Adoption of a new Electronic Health Record (EHR) can introduce radical changes in task allocation, work processes, and efficiency for providers. In June 2019, The Ottawa Hospital ...transitioned from a primarily paper based EHR to a comprehensive EHR (Epic) using a “big bang” approach. The objective of this study was to assess the impact of the transition to Epic on Emergency Physician (EP) work activities in a tertiary care academic Emergency Department (ED).
Methods:
We conducted a time motion study of EPs on shift in low acuity areas of our ED (CTAS 3-5). Fifteen EPs representing a spectrum of pre-Epic baseline workflow efficiencies were directly observed in real-time during two 4-hour sessions prior to EHR implementation (May 2019) and again in go live (August 2019). Trained observers performed continuous observation and measured times for the following EP tasks: chart review, direct patient care, documentation, physical movement, communication, teaching, handover, and other (including breaks). We compared time spent on tasks pre Epic and during go live and report mean times for the EP tasks per patient and per shift using two tailed t-test for comparison.
Results:
All physicians had a 17% decrease in patients seen after Epic implementation (2.72/hr vs 2.24/hr, p < 0.01). EPs spent the same amount of time per patient on direct patient care and chart review (direct patient care: 9min06sec/pt pre vs 8min56sec/pt go live, p = 0.77; chart review: 2min47sec/pt pre vs 2min50sec/pt go live, p = 0.88), however, documentation time increased (5min28sec/pt pre vs 7min12sec/pt go live, p < 0.01). Time spent on shift teaching learners increased but did not reach statistical significance (31min26sec/shift pre vs 36min21sec/shift go live, p = 0.39), and time spent on non-patient-specific activities – physical movement, handover, team communication, and other – did not change (50min49sec/shift pre vs 50min53sec/shift go live, p = 0.99).
Conclusion:
Implementation of Epic did not affect EP time with individual patients - there was no change in direct patient care or chart review. Documentation time increased and EP efficiency (patients seen per hr on shift) decreased after go live. Patient volumes cannot be adjusted in the ED therefore anticipating the EHR impact on EP workflow is critical for successful implementation. EDs may consider up staffing 20% during go live. Findings from this study can inform how to best support EDs nationally through transition to EHR.
More Time for Doctoring Hunt, Rachel J; Fletcher, Shelley; Rock, Jack P ...
Neurosurgery,
12/2020, Volume:
67, Issue:
Supplement_1
Journal Article
Peer reviewed
INTRODUCTION The introduction of the electronic medical record (EMR) has significantly changed physician workflow. Staying late to finish notes is the norm, and the documentation burden imposed by ...EMR has been cited as a significant factor in physician burnout. Junior surgical residents in some institutions have been reported to spend as much as 30% of their time on chart review and documentation. METHODS The neurosurgery written handoff, previously designed by the Henry Ford neurosurgery residents to improve communication during patient handoff, was reviewed with medical coders. With minor alterations to the template, the information contained in the written handoff was determined to be sufficient for billing requirements. The written handoff was then filed as the daily physician progress note in lieu of the traditional SOAP note. After one year, the incidence of coding queries and missed billing opportunities were audited to ensure that billing was not negatively impacted. RESULTS The integrated progress note/handoff format was implemented in February of 2019. Because maintaining a written handoff was already vital to team workflow, the integrated note/handoff format essentially removed the busywork of writing daily progress notes. Residents unanimously reported a decrease in time spent on documentation. Progress note-related coding queries decreased by 44%. Missed billing opportunities due to insufficient documentation decreased by 67%. There was no change in the incidence of coding queries related to other forms of documentation. CONCLUSION Integration of a written handoff with physician daily progress note decreased physician documentation burden while simultaneously improving note usability for billing. Prior studies have shown that the use of standardized written handoff significantly reduces medical errors. Combining the concept of the physician progress note with a written handoff has the potential to improve patient care while simulataneously providing junior neurosurgery residents with more time to spend honing their operative skills.
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