Aims and objectives. To assess agreement between data retrieved from interviews with nurses and data from electronic patient records (EPR) about hospitalised patients’ symptoms, clinical signs and ...treatment during the last three days of life.
Background. Patient records have been used to map symptom prevalence in dying hospitalised patients. However, deficiencies have been found regarding nursing documentation. To our knowledge, this is the first study to assess the agreement between nurse interviews and patient electronic records during the last three days of life in a hospital.
Design. This retrospective study was undertaken in a Norwegian hospital.
Method. We used the resident assessment instrument for palliative care to interview nurses on 112 dying patients, and we independently extracted data from EPR. The agreement between the two data sets was computed with the kappa coefficient. Sensitivity and specificity were calculated. Interview data were used as a reference.
Results. The agreement between the two data sets ranged from poor to good and was highest among symptom variables, including pain, dyspnoea, nausea and the clinical sign falls. In contrast, several clinical variables ranged from poor to fair levels of agreement. The majority of the treatment variables ranged from moderate to good levels of agreement.
Conclusions. Data from the EPR on symptoms (e.g., pain, dyspnoea and nausea) and treatment variables appeared to be reliable and trustworthy, but the data related to fatigue, dry mouth, bloating and sleep interfering with normal functioning should be interpreted carefully.
Relevance to clinical practice. This study contributed to knowledge of agreement between data from nurse interviews and electronic records on symptoms, clinical signs and treatment of dying patients in last three days of life.
When a west central Florida hospital prepared to move to an electronic health record with a clinical documentation system, the nursing staff and administration were concerned about the effects that ...the technology change would have on nursing work behavior. Specifically, would the move toward automation increase the time at the bedside, decrease the time nurses spent on documentation, and decrease time spent on administrative tasks? A time-in-motion study was conducted to specifically measure six categories of nurse work behavior on a progressive cardiac unit. The nurses were observed by data collectors prior to the implementation of the electronic health record and then again a year after the implementation. Results showed a significant increase (P=.000) in the amount of time nurses devoted to direct care. Furthermore, there was a significant increase (P=.000) in the time nurses spent documenting after the implementation of the electronic system. Much of the increased time available for direct care and documentation came from a 12% decrease in the time nurses spent on administrative tasks after implementing the automated documentation system. For this progressive cardiac unit, the move to automated documentation seems to be a positive step in developing a fully interactive computerized system.
This study determined the accuracy of diagnosis and documentation of delirium in the medical and nursing records of 55 elderly patients with hip fracture (mean age = 78.4, SD = 8.4). These records ...were reviewed retrospectively on a patient's discharge for diagnosis of delirium, and for description of clinical indicators or symptoms of delirium. Additionally, all patients were monitored by one of the research members on days 1, 3, 5, 8, and 12 postoperatively for signs of delirium, as measured by the Confusion Assessment Method (CAM). Clinicians were blinded to the purpose of the study. According to the CAM criteria, the incidence of delirium was 14.5% on postoperative Day 1; 9.1% on postoperative Day 3; 10.9% on postoperative Day 5; 7.7% on postoperative Day 8; and 5.6% on postoperative Day 12. For those same days, no formal diagnosis of delirium or a description of clinical indicators was found in the medical records. In the nursing records, a false-positive documentation of 8.5%, 4%, 4.1%, 4.2%, and 5.9%, respectively was noted. False-negative documentation was found in 87.5%, 80%, 66.7%, 75%, and 50% of the cases on the respective days. Documentation of essential symptoms--namely onset and course of the syndrome--and disturbances in consciousness, attention, and cognition, were seldom or never found in the nursing records. However, behaviors of the hyperactive variant of delirium and which are known to interfere with nursing care were documented more often (e.g., 13.4% restless, 10.3% fidget with materials, 7.2% annoying behavior). Both medical and nursing records showed poor documentation and under-diagnosis of delirium. However, a correct diagnosis and early recognition of delirium may enhance the management of this syndrome.
A user friendly interface can enhance the efficiency of data entry, which is crucial for building a complete database. In this study, two user interfaces (traditional pull-down menu vs. check boxes) ...are proposed and evaluated based on medical records with fever medication orders by measuring the time for data entry, steps for each data entry record, and the complete rate of each medical record. The result revealed that the time for data entry is reduced from 22.8 sec/record to 3.2 sec/record. The data entry procedures also have reduced from 9 steps in the traditional one to 3 steps in the new one. In addition, the completeness of medical records is increased from 20.2% to 98%. All these results indicate that the new user interface provides a more user friendly and efficient approach for data entry than the traditional interface.
Information technological advances to develop health care-related systems, Improve clinical efficiency through introducing information technology, Simplify processes to enhance the quality of nursing ...care. Study investigated the regional hospital nurses after initial information system the use of satisfaction surveys, Study for unit 50-bit nurse the use questionnaires collection, not satisfied is 30%, For analysis in found to be not satisfied. 1. Aged between 38-50 years old. 2. The operating practices are not familiar. 3. Typing is siow the fee time is more long. 4. The slow operation of the system. 5. Information ability is low. For the above reasons and after improvement and guidance dissatisfaction reduced to 5%, multi-enhancing information related to education and training in future, Increase nurses information literacy competency.
Transporting the critically ill patient is described within the literature as a high-risk procedure. Both guidelines and minimum standards are available to inform practice. However, a practical, ...clinically useful, and evidence-based document (tool) for the ICU nurse to use when transporting a critically ill patient was not identified in the literature. Consequently, the development of an intrahospital transport tool is described. This transport tool was designed to mitigate the risks associated with patient transport by providing the Intensive Care Unit (ICU) nurse with an integrated documentation record, incorporating patient assessment with a procedural guideline. The result is a framework for the ICU nurse to use throughout intrahospital transfers, informing and supporting them to provide and document continuity of nursing care. The potential benefit of using this tool is enhanced patient outcomes through safer ICU intrahospital transport processes.
Objective. This work sought to assess the inter-observer agreement among expert nurses by using digital photographs and between these experts and the nursing registries in the electronic clinical ...record in the identification and degree of PL. Methods. This was an observational study, including 225 photographic records (184 patients, 97 with pressure lesion and 128 registries without lesion) randomly selected from the total of photographs registered in the PENFUP clinical trial (without lesion). Three expert evaluators assessed said photographs in masked manner. The notes from nursing of patients included related with the description of PL were evaluated. The Kappa index was calculated along with the composite agreement ratio for each evaluation. Results. Good agreement was observed among expert evaluators of photographic records on the presence of PL and between good-moderate for the degree of PL (I-II). Likewise, upon evaluating the agreement between the nursing registries of PL and the photographic assessment of the three expert evaluators of the same areas, good agreement was observed to determine the presence of PL and moderate agreement for the degrees of PL. Conclusion. Photographic records are a tool that permits recognizing the types of wounds, as well as the visualization of the different layers of skin injured. The study highlights the importance of assessment and validation by experts, given that it permits identifying existing problems that can lead to the underestimation or overestimation of PL when conducted by a single caregiver. Descriptors: pressure ulcer; nursing assessment; reproducibility of results; nursing records; observer variation; electronic health records; photography.
This Time and Motion study was part of a larger Open Source Development Project to evaluate the use of Tablet computers for collecting patient data in rural clinics in the OR Tambo District, Eastern ...Cape, South Africa. The intention was to determine if there were any differences in the activities and workloads between the two methods of data capture. The main difference between the Phases was that the number of activities undertaken per patient decreased in the second phase. More time was spent on each activity.
PDF