scholarly journals Patient participation in electronic nursing documentation: an interview study among community nurses

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Kim De Groot ◽  
Elisah B. Sneep ◽  
Wolter Paans ◽  
Anneke L. Francke

Abstract Background Patient participation in nursing documentation has several benefits like including patients’ personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses’ experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation. Methods A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection–data analysis–more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting. Results Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients’ trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient’s home. Nurses still tried to achieve patient participation by verbally discussing patients’ views on the nursing care provided and then documenting those views at a later moment. Conclusions Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.

2021 ◽  
Author(s):  
Mollie Hobensack ◽  
Marietta Ojo ◽  
Kathryn Bowles ◽  
Margaret McDonald ◽  
Jiyoun Song ◽  
...  

Clinicians’ perspectives on the electronic health records (EHR) in home healthcare (HHC) are understudied. To explore this topic, qualitative interviews were conducted with 15 HHC clinicians in the Northeastern USA. Thematic analysis was conducted to identify key themes emerging from the interviews. While some EHR benefits were recognized, overall satisfaction with the EHR was low. The results suggest EHR limitations are tied to poor usability, restrictions, and redundancy in documentation leading to increased documentation workload. Clinicians have recommendations to mitigate these limitations via additional EHR functions and better patient risk detection. Future stakeholders should consider the results of this study when developing and updating the EHR in HHC.


Author(s):  
Andrew L. Yin ◽  
Winston L. Guo ◽  
Evan T. Sholle ◽  
Mangala Rajan ◽  
Mark N. Alshak ◽  
...  

Author(s):  
John Loft ◽  
Diana Greene

Medical records are a type of administrative record with rich potential for research of behavioral health and health policy. Developments in electronic health records (EHR) can increase access to data contained in medical records but also present some unusual challenges for research. This presentation summarizes recent literature describing the use of EHR in research and identifies issues for consideration in the preparation of research design and protocols for data collection and preparation. The discussion is presented in a framework for evaluation of data quality and fitness for use.


2015 ◽  
Vol 22 (2) ◽  
pp. 426-434 ◽  
Author(s):  
Ann S. O’Malley ◽  
Kevin Draper ◽  
Rebecca Gourevitch ◽  
Dori A. Cross ◽  
Sarah Hudson Scholle

Abstract Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.


2018 ◽  
Vol 26 (1) ◽  
pp. 66-70 ◽  
Author(s):  
Chris Grasso ◽  
Michal J McDowell ◽  
Hilary Goldhammer ◽  
Alex S Keuroghlian

AbstractLesbian, gay, bisexual, transgender, and queer (LGBTQ) people experience significant health disparities across the life course and require health care that addresses their unique needs. Collecting information on the sexual orientation and gender identity (SO/GI) of patients and entering SO/GI data in electronic health records has been recommended by the Institute of Medicine, the Joint Commission, and the Health Resources and Services Administration as fundamental to improving access to and quality of care for LGBTQ people. Most healthcare organizations, however, have yet to implement a system to collect SO/GI data due to multiple barriers. This report addresses those concerns by presenting recommendations for planning and implementing high-quality SO/GI data collection in primary care and other health care practices based on current evidence and best practices developed by a federally qualified health center and leader in LGBTQ health care.


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