Patient-Centered Documentation

Allan, Jennifer; Englebright, Jane

doi:10.1097/00005110-200002000-00006

Cited by 52 publications

(5 citation statements)

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“…This level of standardization is to promote decreased practice variability and improved patient outcomes. Standardization of nursing care enables nurse managers to monitor staff compliance with care standards and track improvements in care processes by validating interventions and determining the effectiveness of nursing care through research and clinical audit [18]. This enhances safety and reduces errors by incorporating the best available evidence for practice.…”

Section: The Study Settingmentioning

confidence: 99%

Nurses’ Knowledge of Blood Glucose levels and the management of Hypoglycaemia and Hyperglycaemia: A Descriptive Study

Waheed¹

2017

Madridge J Nurs

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Diabetes has been among the leading causes of mortality, morbidity and disability around the world. Literature indicates that patient education is vital for diabetes control and management. However, research has shown that nurses' (who are at the forefront of care) knowledge of diabetes is variable and not sufficient in the researched populations.This study sought to identify and describe the level of diabetes knowledge and the management of hypoglycaemia and hyperglycaemia among nursing staff of a tertiary teaching hospital in South Australia.A descriptive study design was used with structured observation to gather data on blood glucose monitoring practice and a survey to obtain information on the level of knowledge of diabetes as data collection methods. A convenience sample of nurses, who were directly involved in the provision of care for diabetic patients was observed during blood glucose monitoring and were given a questionnaire to be completed.Approval for the study was gained from the hospital's Research Ethics Committee. The observation checklist and the survey questionnaire were scored by hand and entered into SPSS and reviewed for data entry accuracy. Descriptive statistics were used to summarize the data. Non-parametric statistics were used to compare the knowledge scores between the mentioned groups since the data were not normally distributed. Pearson product-moment coefficient was used to describe the strength and direction of correlation between selected variables.Twenty nurses completed the questionnaire and 32 nurses were observed during their practice. The results of this study showed that the demographic data were not correlated with higher knowledge scores or higher observation scores. However, a statistically significant, positive correlation was found between hospital accreditation for blood glucose monitoring and practices score.It is recommended that this study be replicated in other units of the hospital to see whether the same results could be achieved.

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Section: The Study Settingmentioning

confidence: 99%

Nurses’ Knowledge of Blood Glucose levels and the management of Hypoglycaemia and Hyperglycaemia: A Descriptive Study

Waheed¹

2017

Madridge J Nurs

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“…18 On the other hand, provision of care requires the documentation of clinical information as an intrinsic aspect of routine clinical activity and is essential from both professional and legal standpoints. Thus, clinicians will consider a system to be efficient if the system reduces their documentation time, 19 even if the time savings do not translate into better patient care. 20 For this reason, in evaluating the impact of EHR on clinician activities, some studies use documentation time as a primary outcome and direct patient care time as a secondary outcome.…”

mentioning

confidence: 99%

The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review

Poissant

Pereira²,

Tamblyn³

et al. 2005

Journal of the American Medical Informatics Association

714

456

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A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses.

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“…Studies have investigated the effects of structured data documentation and found that it led to more comprehensive and multidisciplinary communication regarding patients’ needs and also more detailed information about interventions and actions plans. 24,98,89 According to the Donabedian Model, improvements in the structure of care (e.g. a Nutrition MDS) should lead to improvements in clinical processes that should in turn improve patient outcomes.…”

Section: Discussionmentioning

confidence: 99%

Speaking the same language: Development of a Nutrition Minimum Data Set for healthcare professionals in primary healthcare

Håkonsen

Pedersen

Bygholm

et al. 2019

Health Informatics J

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Providing the best possible nutritional care requires accurate and precise communication between healthcare professionals. Developing a Nutrition Minimum Data Set will inform professionals in primary healthcare of which core elements should be documented and facilitate a standardized approach to the documentation of nutritional care. A two-step methodological approach was utilized in this study: (1) a systematic scoping review was conducted to map evidence underpinning the development of a Minimum Data Set and (2) the datasources were categorized using the inductive content analysis approach. A total of 32 items were identified in the datasources. Five categories were inductively derived from the data: (1) physiologic measurements, (2) ability to eat, (3) intake, (4) stress factors and (5) factors which indirectly affect intake and needs. Organizing the documentation following the structure presented in this Minimum Data Set will contribute to a standardized terminology, which may lead to increased quality of documentation, increased continuity of care and improved health outcomes.

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Patient-Centered Documentation

Cited by 52 publications

References 0 publications

Nurses’ Knowledge of Blood Glucose levels and the management of Hypoglycaemia and Hyperglycaemia: A Descriptive Study

Nurses’ Knowledge of Blood Glucose levels and the management of Hypoglycaemia and Hyperglycaemia: A Descriptive Study

The Impact of Electronic Health Records on Time Efficiency of Physicians and Nurses: A Systematic Review

Speaking the same language: Development of a Nutrition Minimum Data Set for healthcare professionals in primary healthcare

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