Int J Med Inform - Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes.

Tópicos

{ record(1888) medic(1808) patient(1693) }
{ assess(1506) score(1403) qualiti(1306) }
{ care(1570) inform(1187) nurs(1089) }
{ age(1611) year(1155) adult(843) }
{ import(1318) role(1303) understand(862) }
{ use(976) code(926) identifi(902) }
{ data(1737) use(1416) pattern(1282) }
{ clinic(1479) use(1117) guidelin(835) }
{ compound(1573) activ(1297) structur(1058) }
{ data(3008) multipl(1320) sourc(1022) }
{ imag(1947) propos(1133) code(1026) }
{ risk(3053) factor(974) diseas(938) }
{ signal(2180) analysi(812) frequenc(800) }
{ use(2086) technolog(871) perceiv(783) }
{ data(1714) softwar(1251) tool(1186) }
{ method(984) reconstruct(947) comput(926) }
{ visual(1396) interact(850) tool(830) }
{ studi(1119) effect(1106) posit(819) }
{ howev(809) still(633) remain(590) }
{ studi(1410) differ(1259) use(1210) }
{ state(1844) use(1261) util(961) }
{ sampl(1606) size(1419) use(1276) }
{ first(2504) two(1366) second(1323) }
{ intervent(3218) particip(2042) group(1664) }
{ model(3404) distribut(989) bayesian(671) }
{ can(774) often(719) complex(702) }
{ inform(2794) health(2639) internet(1427) }
{ system(1976) rule(880) can(841) }
{ measur(2081) correl(1212) valu(896) }
{ imag(1057) registr(996) error(939) }
{ bind(1733) structur(1185) ligand(1036) }
{ sequenc(1873) structur(1644) protein(1328) }
{ method(1219) similar(1157) match(930) }
{ featur(3375) classif(2383) classifi(1994) }
{ imag(2830) propos(1344) filter(1198) }
{ network(2748) neural(1063) input(814) }
{ imag(2675) segment(2577) method(1081) }
{ patient(2315) diseas(1263) diabet(1191) }
{ take(945) account(800) differ(722) }
{ studi(2440) review(1878) systemat(933) }
{ motion(1329) object(1292) video(1091) }
{ treatment(1704) effect(941) patient(846) }
{ surgeri(1148) surgic(1085) robot(1054) }
{ framework(1458) process(801) describ(734) }
{ problem(2511) optim(1539) algorithm(950) }
{ error(1145) method(1030) estim(1020) }
{ chang(1828) time(1643) increas(1301) }
{ learn(2355) train(1041) set(1003) }
{ concept(1167) ontolog(924) domain(897) }
{ algorithm(1844) comput(1787) effici(935) }
{ extract(1171) text(1153) clinic(932) }
{ method(1557) propos(1049) approach(1037) }
{ design(1359) user(1324) use(1319) }
{ control(1307) perform(991) simul(935) }
{ model(2220) cell(1177) simul(1124) }
{ general(901) number(790) one(736) }
{ search(2224) databas(1162) retriev(909) }
{ featur(1941) imag(1645) propos(1176) }
{ case(1353) use(1143) diagnosi(1136) }
{ data(3963) clinic(1234) research(1004) }
{ perform(999) metric(946) measur(919) }
{ research(1085) discuss(1038) issu(1018) }
{ system(1050) medic(1026) inform(1018) }
{ model(2341) predict(2261) use(1141) }
{ perform(1367) use(1326) method(1137) }
{ blood(1257) pressur(1144) flow(957) }
{ spatial(1525) area(1432) region(1030) }
{ health(3367) inform(1360) care(1135) }
{ model(3480) simul(1196) paramet(876) }
{ monitor(1329) mobil(1314) devic(1160) }
{ ehr(2073) health(1662) electron(1139) }
{ research(1218) medic(880) student(794) }
{ patient(2837) hospit(1953) medic(668) }
{ model(2656) set(1616) predict(1553) }
{ data(2317) use(1299) case(1017) }
{ medic(1828) order(1363) alert(1069) }
{ cost(1906) reduc(1198) effect(832) }
{ group(2977) signific(1463) compar(1072) }
{ gene(2352) biolog(1181) express(1162) }
{ activ(1138) subject(705) human(624) }
{ time(1939) patient(1703) rate(768) }
{ patient(1821) servic(1111) care(1106) }
{ can(981) present(881) function(850) }
{ analysi(2126) use(1163) compon(1037) }
{ health(1844) social(1437) communiti(874) }
{ structur(1116) can(940) graph(676) }
{ high(1669) rate(1365) level(1280) }
{ cancer(2502) breast(956) screen(824) }
{ use(1733) differ(960) four(931) }
{ drug(1928) target(777) effect(648) }
{ result(1111) use(1088) new(759) }
{ implement(1333) system(1263) develop(1122) }
{ survey(1388) particip(1329) question(1065) }
{ estim(2440) model(1874) function(577) }
{ decis(3086) make(1611) patient(1517) }
{ process(1125) use(805) approach(778) }
{ activ(1452) weight(1219) physic(1104) }
{ method(1969) cluster(1462) data(1082) }
{ method(2212) result(1239) propos(1039) }
{ detect(2391) sensit(1101) algorithm(908) }

Resumo

RPOSE: To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment.METHODS: This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated.RESULTS: Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms).CONCLUSIONS: Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

Resumo Limpo

rpose describ nurs assess document practic age care organ evalu qualiti electron versus paperbas document nurs assessmentmethod retrospect nurs document audit studi studi sampl paperbas electron resid assess form contain paperbas electron resid nurs record respect three age care organ practic nurs assess document particip age care home describ three attribut qualiti nurs assess document evalu format structur process content seven measur quantiti complet timeli comprehens frequenc document specif care domain data item whether assess form sign datedresult vari practic document nurs assess found among differ age care organ home electron resid record contain higher number comprehens resid assess form paperbas record frequenc document higher electron paperbas record relat care domain differ two type document system aspect nurs assess document overal complet timeli variat frequenc among differ care domain item complet person hygien assess formsconclus electron nurs document system improv qualiti document structur format process content aspect quantiti comprehens sign date assess form studi need understand factor lead variat practic limit nurs assess document evalu document qualiti clinic perspect

Resumos Similares

Int J Med Inform - The effects of an electronic medical record on the completeness of documentation in the anesthesia record. ( 0,873615174082843 )
J Am Med Inform Assoc - Electronic health records improve clinical note quality. ( 0,81377456722151 )
J Am Med Inform Assoc - Clinical documentation: composition or synthesis? ( 0,803079713159591 )
AMIA Annu Symp Proc - Capture of osteoporosis and fracture information in an electronic medical record database from primary care. ( 0,798622580084669 )
J Am Med Inform Assoc - Data from clinical notes: a perspective on the tension between structure and flexible documentation. ( 0,794466688602147 )
AMIA Annu Symp Proc - Lexical concept distribution reflects clinical practice. ( 0,791431091663573 )
AMIA Annu Symp Proc - Continuity of Care Document (CCD) Enables Delivery of Medication Histories to the Primary Care Clinician. ( 0,78295637317615 )
AMIA Annu Symp Proc - Prevalence and Clinical Significance of Discrepancies within Three Computerized Pre-Admission Medication Lists. ( 0,780828176849289 )
Comput. Biol. Med. - A closer look at nursing documentation on paper forms: preparation for computerizing a nursing documentation system. ( 0,780519889122821 )
Int J Med Inform - The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care. ( 0,77459534175883 )
J Am Med Inform Assoc - Electronic medical record use in pediatric primary care. ( 0,771427993114243 )
Methods Inf Med - Survey on medical records and EHR in Asia-Pacific region: languages, purposes, IDs and regulations. ( 0,77035141580989 )
Appl Clin Inform - Relationship between documentation method and quality of chronic disease visit notes. ( 0,768277207490931 )
AMIA Annu Symp Proc - You can lead a horse to water: physicians' responses to clinical reminders. ( 0,765052057182738 )
J Am Med Inform Assoc - Automating the medication regimen complexity index. ( 0,764645146622076 )
Int J Med Inform - Structured electronic operative reporting: comparison with dictation in kidney cancer surgery. ( 0,763412829012748 )
J Am Med Inform Assoc - Use of electronic medical records differs by specialty and office settings. ( 0,761027134808625 )
Int J Med Inform - Concept and implementation of a computer-based reminder system to increase completeness in clinical documentation. ( 0,758275863242675 )
AMIA Annu Symp Proc - Validation and enhancement of a computable medication indication resource (MEDI) using a large practice-based dataset. ( 0,752921579258995 )
BMC Med Inform Decis Mak - Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support. ( 0,751841097830627 )
J Med Syst - An approach to medical knowledge sharing in a hospital information system using MCLink. ( 0,751748945751599 )
AMIA Annu Symp Proc - The physical attractiveness of electronic physician notes. ( 0,749794255354888 )
Comput. Biol. Med. - Clinicians' evaluation of computer-assisted medication summarization of electronic medical records. ( 0,74598498868708 )
J Am Med Inform Assoc - Data quality assessment in healthcare: a 365-day chart review of inpatients' health records at a Nigerian tertiary hospital. ( 0,745694125109453 )
Appl Clin Inform - An analysis of free-text alcohol use documentation in the electronic health record: early findings and implications. ( 0,744963849871938 )
Comput Methods Programs Biomed - Comparison of documentation time between an electronic and a paper-based record system by optometrists at an eye hospital in south India: a time-motion study. ( 0,738092441985943 )
Appl Clin Inform - Determining primary care physician information needs to inform ambulatory visit note display. ( 0,726240098529349 )
Health Informatics J - Clinical Document Architecture integration system to support patient referral and reply letters. ( 0,722750557590612 )
J. Med. Internet Res. - Aligning medication reconciliation and secure messaging: qualitative study of primary care providers' perspectives. ( 0,720169974600428 )
AMIA Annu Symp Proc - Potential value of health information exchange for people with epilepsy: crossover patterns and missing clinical data. ( 0,718249234897129 )
J Am Med Inform Assoc - Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. ( 0,716263193721889 )
Med Decis Making - Impact of Diabetes E-Consults on Outpatient Clinic Workflow. ( 0,715207458030963 )
J Med Syst - Electronic hand-drafting and picture management system. ( 0,713598436890151 )
J Am Med Inform Assoc - HARVEST, a longitudinal patient record summarizer. ( 0,713310466606591 )
J Am Med Inform Assoc - Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. ( 0,713240572090811 )
Int J Med Inform - The effects of EMR deployment on doctors' work practices: a qualitative study in the emergency department of a teaching hospital. ( 0,712881130969976 )
AMIA Annu Symp Proc - Comparing content coverage in medical curriculum to trainee-authored clinical notes. ( 0,709789355882305 )
AMIA Annu Symp Proc - Use of simulated physician handoffs to study cross-cover chart biopsy in the electronic medical record. ( 0,708617634589443 )
Appl Clin Inform - Rapid implementation of inpatient electronic physician documentation at an academic hospital. ( 0,70859751584182 )
Telemed J E Health - Tele-assistance Respiratory card: feasibility of self-reporting in patients with severe COPD. ( 0,70573142095476 )
Int J Med Inform - Supporting medical communication for older patients with a shared touch-screen computer. ( 0,705670511783743 )
J Am Med Inform Assoc - Presence of key findings in the medical record prior to a documented high-risk diagnosis. ( 0,699629123622622 )
AMIA Annu Symp Proc - Analysis of medication and indication occurrences in clinical notes. ( 0,699035053416288 )
AMIA Annu Symp Proc - Information Requirements for Health Information Exchange Supported Communication between Emergency Departments and Poison Control Centers. ( 0,698849891466948 )
Int J Med Inform - The peace of paper: patient lists as work tools. ( 0,698575898593259 )
J Am Med Inform Assoc - Design and evaluation of a wireless electronic health records system for field care in mass casualty settings. ( 0,698047125388503 )
Int J Health Geogr - Identifying risk factors for healthcare-associated infections from electronic medical record home address data. ( 0,697951241081444 )
Int J Med Inform - Separate may not be equal: a preliminary investigation of clinical correlates of electronic psychiatric record accessibility in academic medical centers. ( 0,69249394958425 )
Comput. Biol. Med. - Informatics can identify systemic sclerosis (SSc) patients at risk for scleroderma renal crisis. ( 0,692382791363205 )
Health Informatics J - Sources of variation in primary care clinical workflow: implications for the design of cognitive support. ( 0,691903118299061 )
J. Med. Internet Res. - Use of an electronic patient portal among the chronically ill: an observational study. ( 0,688475243307336 )
J Am Med Inform Assoc - Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records. ( 0,686741834624779 )
Appl Clin Inform - Analysis of free text with omaha system targets in community-based care to inform practice and terminology development. ( 0,686466823493529 )
Int J Med Inform - Preparing the ground for the 'paperless hospital': a case study of medical records management in a UK outpatient services department. ( 0,684367844237854 )
Int J Med Inform - Does the introduction of an electronic nursing documentation system in a nursing home reduce time on documentation for the nursing staff? ( 0,68337842654283 )
J Med Syst - Evaluation of the medical records system in an upcoming teaching hospital-a project for improvisation. ( 0,678704016846894 )
J Am Med Inform Assoc - Electronic medical records and physician stress in primary care: results from the MEMO Study. ( 0,678042184906989 )
Int J Med Inform - Evaluation of the national nursing model and four nursing documentation systems in Finland--lessons learned and directions for the future. ( 0,676268525494407 )
J Am Med Inform Assoc - Implementation of the Department of Veterans Affairs' first point-of-care clinical trial. ( 0,663835043386814 )
Int J Med Inform - Using electronic medical records to determine the diagnosis of clinical depression. ( 0,661488988736257 )
J Med Syst - RBAC-Matrix-based EMR right management system to improve HIPAA compliance. ( 0,66085465926733 )
BMC Med Inform Decis Mak - Improving the effectiveness of electronic health record-based referral processes. ( 0,657030001774437 )
Int J Med Inform - Views on health information sharing and privacy from primary care practices using electronic medical records. ( 0,655777504906863 )
J Am Med Inform Assoc - A framework for assessing patient crossover and health information exchange value. ( 0,654768908970389 )
J Med Syst - A secure integrated medical information system. ( 0,654361835592536 )
J Am Med Inform Assoc - Predicting biomedical document access as a function of past use. ( 0,653299563659544 )
Int J Med Inform - Perceptions regarding the ease of use and usefulness of health information exchange systems among medical providers, case managers and non-clinical staff members working in HIV care and community settings. ( 0,652774755709687 )
AMIA Annu Symp Proc - Who said it? Establishing professional attribution among authors of Veterans' Electronic Health Records. ( 0,652517811292665 )
BMC Med Inform Decis Mak - A study of general practitioners' perspectives on electronic medical records systems in NHSScotland. ( 0,650908920765095 )
J Am Med Inform Assoc - Implementing an interface terminology for structured clinical documentation. ( 0,650562086020379 )
J Am Med Inform Assoc - Patient access to medical records and healthcare outcomes: a systematic review. ( 0,646415475505602 )
J. Med. Internet Res. - Parent satisfaction with the electronic medical record in an academic pediatric rheumatology practice. ( 0,645426536611748 )
BMC Med Inform Decis Mak - Impact of a computerized system for evidence-based diabetes care on completeness of records: a before-after study. ( 0,644315002519164 )
J Biomed Inform - Development of a clinician reputation metric to identify appropriate problem-medication pairs in a crowdsourced knowledge base. ( 0,640995347974154 )
AMIA Annu Symp Proc - Corpus-Based Problem Selection for EHR Note Summarization. ( 0,640857086703692 )
Appl Clin Inform - What do physicians read (and ignore) in electronic progress notes? ( 0,639648098638666 )
BMC Med Inform Decis Mak - Determinants of frequency and longevity of hospital encounters' data use. ( 0,638745580655255 )
J Biomed Inform - Effects of time constraints on clinician-computer interaction: a study on information synthesis from EHR clinical notes. ( 0,632878629966267 )
Perspect Health Inf Manag - Workflow and electronic health records in small medical practices. ( 0,631238897829125 )
J Am Med Inform Assoc - Handling anticipated exceptions in clinical care: investigating clinician use of 'exit strategies' in an electronic health records system. ( 0,630712075204946 )
Int J Med Inform - Multi-disciplinary collaboration during ward rounds: embodied aspects of electronic medical record usage. ( 0,628628932521037 )
J Am Med Inform Assoc - Transforming consumer health informatics through a patient work framework: connecting patients to context. ( 0,627144450159642 )
Int J Med Inform - National questionnaire study on clinical ICT systems proofs: physicians suffer from poor usability. ( 0,62662358007708 )
J Am Med Inform Assoc - Evaluating the state of the art in coreference resolution for electronic medical records. ( 0,623739623096498 )
AMIA Annu Symp Proc - An integrated billing application to streamline clinician workflow. ( 0,621624170661281 )
BMC Med Inform Decis Mak - Impact of electronic medical record on physician practice in office settings: a systematic review. ( 0,62150799004094 )
AMIA Annu Symp Proc - Clinical decision support for whole genome sequence information leveraging a service-oriented architecture: a prototype. ( 0,620937053035086 )
J. Med. Internet Res. - Patients who share transparent visit notes with others: characteristics, risks, and benefits. ( 0,618603962402243 )
J Med Syst - Use and satisfaction with electronic health record by primary care physicians in a health district in Brazil. ( 0,617086664901256 )
Int J Med Inform - Issues and questions to consider in implementing secure electronic patient-provider web portal communications systems. ( 0,616565636577001 )
J Biomed Inform - Visual grids for managing data completeness in clinical research datasets. ( 0,613870866449007 )
J Med Syst - An assessment of patient safety in acupuncture process under EMR support. ( 0,613444712823376 )
Int J Med Inform - Socio-technical considerations in epilepsy electronic patient record implementation. ( 0,608211505659684 )
Int J Med Inform - The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. ( 0,605239230918833 )
AMIA Annu Symp Proc - Evaluation of HL7 v2.5.1 electronic case reports transmitted from a healthcare enterprise to public health. ( 0,605031182896152 )
AMIA Annu Symp Proc - Extending the HL7/LOINC Document Ontology Settings of Care. ( 0,603679488367787 )
J Med Syst - A usability framework for speech recognition technologies in clinical handover: a pre-implementation study. ( 0,6014010946225 )
Int J Med Inform - An investigation of the efficacy of electronic consenting interfaces of research permissions management system in a hospital setting. ( 0,601220696301033 )
Int J Med Inform - Kenya's health workforce information system: a model of impact on strategic human resources policy, planning and management. ( 0,601105075520759 )
J Am Med Inform Assoc - Meaningful measurement: developing a measurement system to improve blood pressure control in patients with chronic kidney disease. ( 0,600509712402584 )