Nursing Clinical Documentation Data Retrieval for Hospitalized Older Adults With Heart Failure: Part 2

Abstract

When clinical information systems (CISs) are developed, developers and nurses must discuss how standardized data will be entered to ensure retrieval and usefulness in evaluating nursing care. For nursing effectiveness research, CISs must also provide linkages among nursing diagnoses and specific interventions, and nursing-sensitive patient outcomes.

Minnesota Nurses' Perceptions of Nursing Diagnoses

“…One reason for this may be that in many electronic documentation systems, the care plan is a separate module than the documentation of patient care. This is a critical issue and must be resolved so the care documented and care planned are seen as equally important nursing functions (Head et al., in press).…”

Implications of Electronic Health Record Meaningful Use Legislation for Nursing Clinical Information System Development and Refinement

“…The use of nonstandardized terms in a nursing CIS is an issue that constrains nursing data retrieval and the building of data repositories, especially those that are interoperable among multiple organizations (Head, Scherb, Maas, et al., ). Even when standardized nursing terminologies are used within a system, organizations frequently use some nonstandardized terms in addition.…”

“…Another issue is that nursing CIS designs are frequently not fully integrated in regard to (a) one‐to‐one linkages of nursing‐sensitive outcomes to specific nursing interventions that are used to treat specific nursing diagnoses, and (b) linkage of documented care planned and documented care delivered (Head, Scherb, Maas, et al., ). When one‐to‐one linkages among nursing diagnoses, outcomes, and interventions are not explicit using recognized standardized terminologies in the operational CIS, the specific outcomes that are planned to assess a patient's response to specific interventions that are used to treat specific nursing diagnoses cannot be determined.…”

“…These issues were illustrated by a pilot study with four Midwest hospitals to prepare for a larger nursing effectiveness study conducted by a team of researchers associated with the University of Iowa College of Nursing Center for Nursing Classification and Effectiveness Research (Head, Scherb, Maas, et al., ; Head, Scherb, Reed, et al., ; Scherb et al., ). The pilot study required the study hospitals to retrieve data for a set of variables from their CIS for the first time.…”

“…Several problems were encountered, including the following: (a) data for some variables were not available from all hospitals' CISs because they were not documented electronically; (b) data for some variables were available electronically, but were in other systems not connected to the EHR; (c) data for some variables were not available because the data were not documented electronically or in paper forms; (d) even when standardized nomenclatures were used, there were inconsistencies in the way the same information was documented (e.g., textual descriptions rather than codes and variable text corresponding to a single code); (e) each nursing diagnosis was not linked with specific outcomes and specific nursing interventions to address the outcomes for each diagnosis; and (f) standardized nursing nomenclatures were not used to fully integrate and link care planned with care actually delivered. Because of these problems, complete data could not be retrieved for patient comorbid conditions, medications, race/ethnicity, nursing acuity, severity of illness, occupation, medical and other treatments, and primary language (Head, Scherb, Maas, et al., ). Importantly, data could not be retrieved to analyze the effectiveness of care that was actually received by the patients.…”