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

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

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 a Comprehensive Electronic Health Record to Enhance Nursing Care Coordination, Use of Technology, and Research

2010 ◽  
Vol 36 (1) ◽  
pp. 13-17 ◽  
Author(s):  
Marilyn J. Rantz ◽  
Marjorie Skubic ◽  
Greg Alexander ◽  
Mihail Popescu ◽  
Myra A. Aud ◽  
...  
Keyword(s):  
Electronic Health Record ◽  
Nursing Care ◽  
Care Coordination ◽  
Health Record ◽  
Use Of Technology ◽  
Electronic Health

Business: The Electronic Health Record: Front Line Experience

2011 ◽  
Vol 21 (1) ◽  
pp. 18-22
Author(s):  
Rosemary Griffin
Keyword(s):  
Health Care ◽  
Information Technology ◽  
Electronic Health Record ◽  
Financial Incentives ◽  
Best Practice ◽  
Health Care Systems ◽  
The United States ◽  
Health Record ◽  
Health Trends ◽  
Electronic Health

National legislation is in place to facilitate reform of the United States health care industry. The Health Care Information Technology and Clinical Health Act (HITECH) offers financial incentives to hospitals, physicians, and individual providers to establish an electronic health record that ultimately will link with the health information technology of other health care systems and providers. The information collected will facilitate patient safety, promote best practice, and track health trends such as smoking and childhood obesity.

What Can Human Factors Contribute to Improve Electronic Health Record Usability and Patient Safety?

2012 ◽  
Author(s):  
Robert Schumacher ◽  
Robert North ◽  
Matthew Quinn ◽  
Emily S. Patterson ◽  
Laura G. Militello ◽  
...  
Keyword(s):  
Patient Safety ◽  
Human Factors ◽  
Electronic Health Record ◽  
Health Record ◽  
Electronic Health
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