Abstract
Objective
The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from ...electronic health records (EHRs).
Materials and Methods
We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment.
Results
Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling.
Discussion
SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes.
Conclusions
Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient’s health care experience.
•The CCC has played a role in implementing standard nursing terminology of the ICNP® over the last two decades in South Korea.•Two-thirds of the responding hospitals in the national health ...information exchange network in South Korea recognized the awareness of CCC.•The CCC awareness showed significant relationships with the increase of overall scores for patient experiences.•Clinical use of CCC in practice revealed both prospective opportunities and challenges to overcome to realize the benefits of standardized terminologies.
A government-driven standardization of nursing terminology including the Clinical Care Classification (CCC) was endorsed in South Korea in 2015, but the number of hospitals who have adopted this standard terminology remains unknown. This study aimed to determine the CCC awareness, adoption, and utilization statuses and its association with patient experience in South Korea.
A nationwide telephone survey was conducted from January 13 to February 12, 2022 among 217 tertiary and secondary hospitals participating in the health information exchange network. The survey questionnaire included 22 items in 3 categories: current status of electronic nursing records, awareness and adoption of standard terminology, and open-ended questions regarding standard usage and dissemination. General characteristics and experience scores of the patients of the surveyed hospitals were collected from the publicly available data sources. Data analysis was performed using descriptive statistics, t-test, and generalized linear regression.
The rates of awareness and adoption in hospitals to the nursing terminology standard of the CCC were calculated, and the current status of electronic nursing records used in practice was examined. The relationships between CCC awareness and the characteristics of hospitals in their patient experiences of health services were also identified.
The survey response rate was 24.9 % (54/217). Two out of three hospitals (68.5 %) were aware of the CCC. These hospitals had 800 beds or more, and higher scores for patient experience. CCC awareness was significantly related to increases in the overall scores for patient experiences (t = 2.70, p =.0103), but no significance with sub-score for nursing service (t = 1.23, p =.1594).
With a high adoption rate of electronic medical record systems, two-third hospitals acknowledged their CCC awareness, but were still lagged in adoption and usage of it in practice with operational challenges. The CCC awareness has potential relationships with positive patient experience.
Nursing documentation could improve the quality of nursing care by being an important source of information about patients’ needs and nursing interventions. Standardized terminologies (e.g. NANDA ...International and the Omaha System) are expected to enhance the accuracy of nursing documentation. However, it remains unclear whether nursing staff actually feel supported in providing nursing care by the use of electronic health records that include standardized terminologies.
a. To explore which standardized terminologies are being used by nursing staff in electronic health records. b. To explore to what extent they feel supported by the use of electronic health records. c. To examine whether the extent to which nursing staff feel supported is associated with the standardized terminologies that they use in electronic health records.
Cross-sectional survey design.
A representative sample of 667 Dutch registered nurses and certified nursing assistants working with electronic health records. The respondents were working in hospitals, mental health care, home care or nursing homes.
A web-based questionnaire was used. Descriptive statistics were performed to explore which standardized terminologies were used by nursing staff, and to explore the extent to which nursing staff felt supported by the use of electronic health records. Multiple linear regression analyses examined the association between the extent of the perceived support provided by electronic health records and the use of specific standardized terminologies.
Only half of the respondents used standardized terminologies in their electronic health records. In general, nursing staff felt most supported by the use of electronic health records in their nursing activities during the provision of care. Nursing staff were often not positive about whether the nursing information in the electronic health records was complete, relevant and accurate, and whether the electronic health records were user-friendly. No association was found between the extent to which nursing staff felt supported by the electronic health records and the use of specific standardized terminologies.
More user-friendly designs for electronic health records should be developed. The poor user-friendliness of electronic health records and the variety of ways in which software developers have integrated standardized terminologies might explain why these terminologies had less of an impact on the extent to which nursing staff felt supported by the use of electronic health records.
To understand how nurses talk about documentation audit in relation to their professional role.
Nursing documentation in health services is often audited as an indicator of nursing care and patient ...outcomes. There are few studies exploring the nurses' perspectives on this common process.
Secondary qualitative thematic analysis.
Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study.
Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences.
Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows.
Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation.
Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.
Abstract
Purpose
To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q‐DIO) measurement instrument.
...Methods
A quantitative cross‐sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q‐DIO measurement instrument.
Findings
Low quality levels of nursing process documentation were found. The Q‐DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).
Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q‐DIO sub‐concepts except for “Nursing diagnoses as process.”
Conclusions
The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes.
Implications for nursing practice
This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the
Advanced Nursing Process
.
Aims and objectives
To analyse the Primary Nursing Model's effect on nursing documentation accuracy.
Background
The Primary Nursing is widely implemented since it has been considered as the ideal ...model of care delivery based on the relationship between the nurse and patient. However, previous research has not examined the relationship between Primary Nursing and nursing documentation accuracy.
Design
A pretest‐posttest‐follow‐up design was used.
Methods
The study was conducted from August 2018 to February 2020 in eight surgical and medical wards in an Italian university hospital. The Primary Nursing was implemented in four wards (study group), while in the other four, the Team Nursing was practised (control group). Nursing documentation accuracy was evaluated through the D‐Catch instrument. From the eight wards, 120 nursing documentations were selected randomly for each time point (pre‐test, post‐test and follow‐up) and in each group. Altogether, 720 nursing documents were assessed. The study adhered to the TREND checklist.
Results
The Primary Nursing and Team Nursing Models exhibited significant differences in mean scores for documentation accuracy: assessment on admission, nursing diagnosis, nursing intervention and patient outcome accuracy. No differences between the two groups were found for record structure accuracy and legibility between the posttest and follow‐up.
Conclusion
Primary Nursing exerts an overall positive effect on nursing documentation accuracy and persists over time.
Relevance to clinical practice
The benefits from Primary Nursing implementation included better‐documented patient outcomes. The use of Primary Nursing linked with the use of the nursing process allowed for a more individualised and problem‐solving approach. Nurse managers should consider the implementation of Primary Nursing to improve care quality.
ABSTRACT Objective: To describe the development of computerization of risk prediction scales used by nursing in the AGHUse® system. Method: An experience report of technological production at a ...university hospital, which followed the phases of conception, detailing, construction and prototyping. Results: Different scales were computerized, with emphasis on the Braden and Braden Q, which assess the risk of pressure injuries, and the Severo-Almeida-Kuchenbecker, which assesses the risk of falls. The process of computerization and implementation took place through registration of the scales in the software, application of them in care practice, integration and visualization of their scores with the other functionalities of the electronic medical record. Final considerations: The functionalities developed in the computerization of risk prediction scales favored its operation, reflecting positively on nursing practice and patient safety.
RESUMEN Objetivo: Describir el desarrollo de la informatización de las escalas de predicción de riesgo utilizadas por la enfermería en la historia clínica electrónica, en el sistema AGHUse®. Método: Relato de experiencia de producción tecnológica en un hospital universitario, que siguió las fases de concepción, detalle, construcción y prototipado. Resultados: Se computarizaron diferentes escalas, con énfasis en la Braden y Braden Q, que evalúa el riesgo de lesiones por presión, y la Severo-Almeida-Kuchenbecker, que evalúan el riesgo de caídas. El proceso de informatización e implementación pasó por el registro de las escalas en el software, aplicación de las mismas en la práctica asistencial, integración y visualización de sus puntuaciones con las demás funcionalidades de la historia clínica electrónica. Consideraciones finales: Las funcionalidades desarrolladas en la informatización de las escalas de predicción de riesgo favorecieron su operacionalización, repercutiendo positivamente en la práctica de enfermería y la seguridad del paciente.
RESUMO Objetivo: Descrever o desenvolvimento da informatização de escalas de predição de risco, utilizadas pela enfermagem no prontuário eletrônico, no sistema AGHUse®. Método: Relato de experiência de produção tecnológica em um hospital universitário, que seguiu as fases de concepção, detalhamento, construção e prototipagem. Resultados: Foram informatizadas diferentes escalas, destacando-se as de Braden e de Braden Q, que avaliam risco de lesão por pressão, e a de Severo-Almeida-Kuchenbecker, que avalia risco de quedas. O processo de informatização e implantação ocorreu por meio do cadastro das escalas no software, aplicação delas na prática assistencial, integração e visualização de seus escores em relação às demais funcionalidades do prontuário eletrônico. Considerações finais: As funcionalidades desenvolvidas na informatização das escalas de predição de risco favoreceram a sua operacionalização, refletindo-se positivamente na prática do enfermeiro e na segurança do paciente.
Few studies have used standardized nursing records with Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) to identify predictors of clinical deterioration.
This study aims to ...standardize the nursing documentation records of patients with COVID-19 using SNOMED CT and identify predictive factors of clinical deterioration in patients with COVID-19 via standardized nursing records.
In this study, 57,558 nursing statements from 226 patients with COVID-19 were analyzed. Among these, 45,852 statements were from 207 patients in the stable (control) group and 11,706 from 19 patients in the exacerbated (case) group who were transferred to the intensive care unit within 7 days. The data were collected between December 2019 and June 2022. These nursing statements were standardized using the SNOMED CT International Edition released on November 30, 2022. The 260 unique nursing statements that accounted for the top 90% of 57,558 statements were selected as the mapping source and mapped into SNOMED CT concepts based on their meaning by 2 experts with more than 5 years of SNOMED CT mapping experience. To identify the main features of nursing statements associated with the exacerbation of patient condition, random forest algorithms were used, and optimal hyperparameters were selected for nursing problems or outcomes and nursing procedure-related statements. Additionally, logistic regression analysis was conducted to identify features that determine clinical deterioration in patients with COVID-19.
All nursing statements were semantically mapped to SNOMED CT concepts for "clinical finding," "situation with explicit context," and "procedure" hierarchies. The interrater reliability of the mapping results was 87.7%. The most important features calculated by random forest were "oxygen saturation below reference range," "dyspnea," "tachypnea," and "cough" in "clinical finding," and "oxygen therapy," "pulse oximetry monitoring," "temperature taking," "notification of physician," and "education about isolation for infection control" in "procedure." Among these, "dyspnea" and "inadequate food diet" in "clinical finding" increased clinical deterioration risk (dyspnea: odds ratio OR 5.99, 95% CI 2.25-20.29; inadequate food diet: OR 10.0, 95% CI 2.71-40.84), and "oxygen therapy" and "notification of physician" in "procedure" also increased the risk of clinical deterioration in patients with COVID-19 (oxygen therapy: OR 1.89, 95% CI 1.25-3.05; notification of physician: OR 1.72, 95% CI 1.02-2.97).
The study used SNOMED CT to express and standardize nursing statements. Further, it revealed the importance of standardized nursing records as predictive variables for clinical deterioration in patients.
Aim
To determine the prevalence of NANDA International nursing diagnoses in the coping/stress tolerance domain and their linkages to Nursing Outcomes Classification outcomes and Nursing Interventions ...Classification interventions in the pre‐hospital emergency care setting.
Design
Retrospective descriptive study of electronic record review.
Methods
Eight thousand three hundred three episodes recorded during the year 2019 were recovered from the electronic health records of a public emergency care agency. The prevalence of NANDA International nursing diagnosis, Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions was determined. A cross‐tabulation analysis was performed to determine the linkages. Data were accessed in November 2020.
Results
NANDA International nursing diagnoses Anxiety (00146) and Fear (00148) represented more than 90% of the diagnoses recorded in the domain. Anxiety level (1211) and emotional support (5270) were the most recorded Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions, with almost 20% and 5% of total records, respectively. The linkage between nursing diagnosis Anxiety (00146), outcome Anxiety level (1211) and intervention Anxiety reduction (5820) was the most recorded with slightly more than 3% of the total.
Conclusion
Eight different NANDA International nursing diagnoses in the coping/stress tolerance domain were recorded. Nursing Outcomes Classification outcomes were selected aimed mainly at psychological well‐being and Nursing Interventions Classification interventions to support coping. In general, linkages were aimed to provide emotional support, physical well‐being, information, education and safety.
Impact
This study showed that pre‐hospital emergency care nurses diagnose and treat human responses in the coping/stress tolerance domain. Expert consensus‐based linkages may be complemented by the results of this study, increasing the levels of evidence of both individualized and standardized care plans for critical patients assisted by pre‐hospital emergency care nurses.
Background
Inpatient nursing documentation facilitates multi‐disciplinary team care and tracking of patient progress. In both high‐ and low‐ and middle‐income settings, it is largely paper‐based and ...may be used as a template for electronic medical records. However, there is limited evidence on how they have been developed.
Objective
To synthesise evidence on how paper‐based nursing records have been developed and implemented in inpatient settings to support documentation of nursing care.
Design
A scoping review guided by the Arksey and O'Malley framework and reported using PRISMA‐ScR guidelines.
Eligibility criteria
We included studies that described the process of designing paper‐based inpatient records and excluded those focussing on electronic records. Included studies were published in English up to October 2019.
Sources of evidence
PubMed, CINAHL, Web of Science and Cochrane supplemented by free‐text searches on Google Scholar and snowballing the reference sections of included papers.
Results
12 studies met the eligibility criteria. We extracted data on study characteristics, the development process and outcomes related to documentation of inpatient care. Studies reviewed followed a process of problem identification, literature review, chart (re)design, piloting, implementation and evaluation but varied in their execution of each step. All studies except one reported a positive change in inpatient documentation or the adoption of charts amid various challenges.
Conclusions
The approaches used seemed to work for each of the studies but could be strengthened by following a systematic process. Human‐centred Design provides a clear process that prioritises the healthcare professional's needs and their context to deliver a usable product. Problems with the chart could be addressed during the design phase rather than during implementation, thereby promoting chart ownership and uptake since users are involved throughout the design. This will translate to better documentation of inpatient care thus facilitating better patient tracking, improved team communication and better patient outcomes.
Relevance to clinical practice
Paper‐based charts should be designed in a systematic and clear process that considers patient's and healthcare professional's needs contributing to improved uptake of charts and therefore better documentation.
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