scholarly journals Nursing care management based on the Omaha system for inpatients diagnosed with COVID‐19: An electronic health record study

2021 ◽  
Author(s):  
Aysun Ardic ◽  
Ebru Turan
Keyword(s):  
Electronic Health Record ◽  
Nursing Care ◽  
Care Management ◽  
Health Record ◽  
Omaha System ◽  
Electronic Health

scholarly journals I-THS-1908 A Big Data Electronic Health Record for Patient Care Management and Analytics

2019 ◽  
Author(s):  
Ahmad Hidayat ◽  
Arief Hasani
Keyword(s):  
Big Data ◽  
Electronic Health Record ◽  
Patient Care ◽  
Care Management ◽  
Patient Care Management ◽  
Health Conditions ◽  
Health Record ◽  
Complex Variety ◽  
Electronic Health ◽  
Further Development

The I-THS-1908, a big data electronic health record platform, is capable of establishing its capability as an electronic health record to tackle the large volume of data with high velocity and complex variety of patient data by providing the value to the patient care management and analytics. The further development of I-THS-1908 opens the opportunity to use the electronic health record for patient care management and analytics for all type of health conditions.

scholarly journals Implementation of an Electronic Health Record-Based Care Management System to Improve Tobacco Treatment

2012 ◽  
Vol 27 (12) ◽  
pp. 1690-1696 ◽  
Author(s):  
Gina R. Kruse ◽  
Jennifer H. K. Kelley ◽  
Jeffrey A. Linder ◽  
Elyse R. Park ◽  
Nancy A. Rigotti
Keyword(s):  
Electronic Health Record ◽  
Management System ◽  
Care Management ◽  
Health Record ◽  
Tobacco Treatment ◽  
Electronic Health

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 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 Meaningful Use of a Standardized Terminology to Support the Electronic Health Record in New Zealand

2010 ◽  
Vol 01 (04) ◽  
pp. 368-376 ◽  
Author(s):  
M. Honey ◽  
S. Wilson ◽  
K. Monsen
Keyword(s):  
New Zealand ◽  
Electronic Health Record ◽  
Clinical Information System ◽  
Service Providers ◽  
Meaningful Use ◽  
Free Text ◽  
Health Record ◽  
Snomed Ct ◽  
Omaha System ◽  
Electronic Health

SummaryMeaningful use is a multidimensional concept that incorporates complex processes; workflow; interoperability; decision support; performance evaluation; and quality improvement. Meaningful use is congruent with the overall vision for information management in New Zealand. Health practitioners interface with patient information at many levels, and are pivotal to meaningful use at the interface between service providers, patients, and the electronic health record. Advancing towards meaningful use depends on implementing a meaningful interface terminology within the electronic health record. The Omaha System is an interface terminology that is integrated within Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT®), and has the capacity to disseminate and capture information at the point of care because its codes are simple defined terms. Two community nursing and allied health providers who are considering using the Omaha System in clinical systems for gathering intervention and outcomes data within the personal EHR include Nurse Maude and the Royal New Zealand Plunket Society. Help4U is investigating using the Omaha System as a way to standardise health terminology for consumer use. The Omaha System is also a good fit with the Midwifery and Maternity Providers Organisation (MMPO) existing clinical information system to describe and capture data about interventions currently recorded as free text. As a country that promotes access to affordable primary care and free hospital care, within an environment constrained by resource limitations, maximizing the use of data is key to demonstrating health outcomes for the population.

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.

Developing Structured Omaha System Goals for Use in an Electronic Health Record

2019 ◽  
Vol 37 (12) ◽  
pp. 655-661
Author(s):  
Ann M. OʼNeill ◽  
Michael R. Mossing ◽  
Marci D. Newcome ◽  
Kari B. Miller ◽  
Karen A. Monsen
Keyword(s):  
Electronic Health Record ◽  
Health Record ◽  
Omaha System ◽  
Electronic Health

Digital Health Interventions to Enhance Prevention in Primary Care: A Scoping Review (Preprint)

2021 ◽  
Author(s):  
Van C Willis ◽  
Kelly Jean Thomas Craig ◽  
Yalda Yabbarpour ◽  
Elisabeth L Scheufele ◽  
Yull E Arriaga ◽  
...  
Keyword(s):  
Primary Care ◽  
Electronic Health Record ◽  
Scoping Review ◽  
Subgroup Analysis ◽  
Care Management ◽  
Digital Health ◽  
Health Interventions ◽  
Health Record ◽  
Primary Care Settings ◽  
Electronic Health

BACKGROUND Digital transformation of primary care practices, including the use digital health interventions (DHIs), has yet to be systematically evaluated. OBJECTIVE To identify and describe the scope and use of current DHIs for preventive care in primary care settings. METHODS A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and MeSH terms covering primary care professionals AND prevention and care management AND digital health. A subgroup analysis identified relevant studies conducted in US primary care settings excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (e.g., healthcare performance and implementation science), and study quality as per Oxford Levels of Evidence were abstracted. RESULTS The search yielded 5,274 citations of which 1,060 full-texts were identified. Following a subgroup analysis, 241 articles met inclusion criteria. Studies primarily examined DHIs among health information technology including EHRs (69%), clinical decision support (41%), telehealth (37%), or multiple technologies (61%). DHIs were predominantly used for tertiary prevention (55%). Of the core primary care functions, comprehensiveness was addressed most frequently (87%). DHI users were providers (85%), patients (46%), or multiples (37%). Reported outcomes were primarily clinical (70%) and statistically significant improvements were common (69%). Results were summarized across five topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. Quality of the included studies was moderate-to-low. CONCLUSIONS Preventive DHIs used in primary care settings demonstrated meaningful improvements in both clinical and non-clinical outcomes across user types; however, adoption and implementation in the US was limited to primarily electronic health record-centric platforms and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluation of negative results, effects on health disparities, and many other gaps remain to be explored.

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