Electronic Health Record Documentation of Nursing Care Procedures and Change in Weight of Healthy, Moderately Premature Neonates

2017 ◽  
Vol 36 (6) ◽  
pp. 348-358 ◽  
Author(s):  
Lory Anne Lewis ◽  
Ann F. Jacobson
Keyword(s):  
Electronic Health Record ◽  
Nursing Care ◽  
Thermal Environment ◽  
Outcome Variable ◽  
Preterm Neonates ◽  
Health Record ◽  
Main Outcome Variable ◽  
Moderately Preterm ◽  
Electronic Health ◽  
The Relationship

AbstractPurpose: To identify the nursing care procedures (NCPs) performed in a NICU that disrupt the thermal environment by opening the incubator of moderately preterm neonates (mPNs) (32–34 wk gestational age) and the relationship between the frequency of these disruptions and change in weight (Δwt).Design: Survey and descriptive correlational methodology.Sample: Systematically identified, published references to NCPs that opening the incubator developed an itemized list of NCPs that was used to query the electronic health records (EHRs) of 164 mPNs in the first ten days of life (DOL).Main Outcome Variable: The Δwt between birth and ten DOL.Results: Of 51 NCPs identified, 26 were represented in the EHR. A mean of 614 (range 402–1,080; SD = 137) EHR-documented NCPs that opening the incubator were recorded. The frequency of NCPs was negatively correlated with the Δwt of mPNs at ten DOL, rs (164) = −.162, p = .038.Keywords: premature; neonatal; preterm neonates; neonatal nursing; thermal regulation; change in weight; nursing documentation; electronic health record

scholarly journals The Relationship between Electronic Health Record Use and Quality of Care over Time

2009 ◽  
Vol 16 (4) ◽  
pp. 457-464 ◽  
Author(s):  
L. Zhou ◽  
C. S. Soran ◽  
C. A. Jenter ◽  
L. A. Volk ◽  
E. J. Orav ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Electronic Health Record ◽  
Health Record ◽  
Electronic Health ◽  
The Relationship ◽  
Over Time

scholarly journals The Relationship Between Magnet Designation, Electronic Health Record Adoption, and Medicare Meaningful Use Payments

2017 ◽  
Vol 35 (8) ◽  
pp. 385-391
Author(s):  
Christine Lippincott ◽  
Cynthia Foronda ◽  
Martin Zdanowicz ◽  
Brian E. McCabe ◽  
Todd Ambrosia
Keyword(s):  
Electronic Health Record ◽  
Meaningful Use ◽  
Health Record ◽  
Electronic Health ◽  
The Relationship

scholarly journals PS1-24: Modeling the Relationship Between Self-Reported Urinary Incontinence Data and Diagnoses in an Electronic Health Record

2011 ◽  
Vol 9 (3-4) ◽  
pp. 176-177
Author(s):  
M. Lichtenfeld ◽  
H. Sun ◽  
A. Hirsch ◽  
M. Pfleegor ◽  
J. Reardon ◽  
...  
Keyword(s):  
Urinary Incontinence ◽  
Electronic Health Record ◽  
Health Record ◽  
Electronic Health ◽  
The Relationship

scholarly journals The Implementation of Electronic based Nursing Care Documentation to EFETEC; A Literature Review

2019 ◽  
Vol 1 (2) ◽  
pp. 19-31
Author(s):  
I Wayan Gede Saraswasta ◽  
Rr. Tutik Sri Hariyati
Keyword(s):  
Quality Of Service ◽  
Literature Review ◽  
Electronic Health Record ◽  
Nursing Care ◽  
Health Workers ◽  
Health Record ◽  
Documentation Quality ◽  
Electronic Health ◽  
Quality Of Nursing

ABSTRACT In last two decades most of the tasks performed by nurses have not been directly related to patient care. Nurses spend more time on writing documentation or medical records of patients. Implementation of electronic medical record can reduce the time used for documentation or in other hand will increase the time for nurses to interact with patients then eventually can improve the quality of nursing care. Purpose of this literature review is to find out the implementation of electronic-based nursing care documentation (EHR) in improving the quality of nursing care in terms of EFETEC aspects. Method used by author is a literature review. Database used is Science Direct, PROQUEST, Scopus, Ebscho and Scholar Article with the keywords; electronic health record, EHR, Documentation in nursing, Quality of nursing care. Implementation of electronic nursing care documentation can improve the service quality. Improvement of the quality of service is reviewed with EFETEC which consists of efficient, focus for patient, effective, time discipline, equality, confidentiality. In the era of health workers 4.0 the utilization of electronic nursing care documentation requires continuous development in order to improve the quality of service for patients.  KEYWORDS: electronic health record, nursing care documentation, quality of nursing care

Defining and Incorporating Basic Nursing Care Actions Into the Electronic Health Record

2013 ◽  
Vol 46 (1) ◽  
pp. 50-57 ◽  
Author(s):  
Jane Englebright ◽  
Kelly Aldrich ◽  
Cathy R. Taylor
Keyword(s):  
Electronic Health Record ◽  
Nursing Care ◽  
Health Record ◽  
Electronic Health

scholarly journals The Relationship Between Electronic Health Record System and Performance on Quality Measures in the American College of Rheumatology’s Rheumatology Informatics System for Effectiveness (RISE) Registry: Observational Study

10.2196/31186 ◽  
2021 ◽  
Vol 9 (11) ◽  
pp. e31186
Author(s):  
Nevin Hammam ◽  
Zara Izadi ◽  
Jing Li ◽  
Michael Evans ◽  
Julia Kay ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Quality Measures ◽  
Independent Effect ◽  
Health Record ◽  
Practice Level ◽  
Patient Reported ◽  
Electronic Health ◽  
And Performance ◽  
The Relationship ◽  
Better Than

Background Routine collection of disease activity (DA) and patient-reported outcomes (PROs) in rheumatoid arthritis (RA) are nationally endorsed quality measures and critical components of a treat-to-target approach. However, little is known about the role electronic health record (EHR) systems play in facilitating performance on these measures. Objective Using the American College Rheumatology’s (ACR’s) RISE registry, we analyzed the relationship between EHR system and performance on DA and functional status (FS) quality measures. Methods We analyzed data collected in 2018 from practices enrolled in RISE. We assessed practice-level performance on quality measures that require DA and FS documentation. Multivariable linear regression and zero-inflated negative binomial models were used to examine the independent effect of EHR system on practice-level quality measure performance, adjusting for practice characteristics and patient case-mix. Results In total, 220 included practices cared for 314,793 patients with RA. NextGen was the most commonly used EHR system (34.1%). We found wide variation in performance on DA and FS quality measures by EHR system (median 30.1, IQR 0-74.8, and median 9.0, IQR 0-74.2), respectively). Even after adjustment, NextGen practices performed significantly better than Allscripts on the DA measure (51.4% vs 5.0%; P<.05) and significantly better than eClinicalWorks and eMDs on the FS measure (49.3% vs 29.0% and 10.9%; P<.05). Conclusions Performance on national RA quality measures was associated with the EHR system, even after adjusting for practice and patient characteristics. These findings suggest that future efforts to improve quality of care in RA should focus not only on provider performance reporting but also on developing and implementing rheumatology-specific standards across EHRs.

scholarly journals Abstracting ICU Nursing Care Quality Data From the Electronic Health Record

2016 ◽  
Vol 39 (9) ◽  
pp. 1271-1288 ◽  
Author(s):  
Jennifer B. Seaman ◽  
Anna C. Evans ◽  
Andrea M. Sciulli ◽  
Amber E. Barnato ◽  
Susan M. Sereika ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Electronic Health Record ◽  
Nursing Care ◽  
Pragmatic Trial ◽  
Care Quality ◽  
Quality Data ◽  
Health Record ◽  
Nursing Care Quality ◽  
Electronic Health

The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen’s kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.

A Comparison of Moderate to Late Preterm Neonates Receiving Nasal Continuous Positive Airway Pressure in Australian Tertiary and Nontertiary Centers

2020 ◽  
Vol 39 (4) ◽  
pp. 189-199
Author(s):  
Helen Ruth Patterson ◽  
Wendy Pollock
Keyword(s):  
Continuous Positive Airway Pressure ◽  
Airway Pressure ◽  
Positive Airway Pressure ◽  
Outcome Variable ◽  
Preterm Neonates ◽  
Short Term ◽  
Term Outcome ◽  
Observational Cohort ◽  
Main Outcome Variable ◽  
Moderately Preterm

PurposeTransfer of neonates ≥32 weeks' gestation with acute respiratory distress to tertiary (T) centers can be reduced by treatment with nasal continuous positive airway pressure (nCPAP) in nontertiary (NT) centers. This can lead to considerable financial and emotional benefits. The aim of this project was to compare management of nCPAP in T and NT centers.DesignFive-year retrospective, observational cohort study (2010–2014).SampleAll NT eligible neonates from four sites (n = 484) were compared with a similar randomized cohort of inborn neonates at two T centers (n = 601) in Victoria, Australia.Main outcome variableAny difference in management or short-term outcome.ResultsModerately preterm and term neonates born in NT centers had lower Apgar scores at five minutes of age and received more conservative management delivered by different equipment. Despite a higher incidence of air leaks in NT centers, the short-term outcomes were otherwise similar between centers. T centers were more likely to administer nCPAP to term babies for <24 hours.

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