Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Experiment Videos

Embedding clinical indicators into nursing documentation.

Jennifer Allan Browne1, Barbara G Covington

  • 1Department of Nursing Informatics, Methodist Healthcare System of San Antonio, 8109 Fredericksburg Road, San Antonio, TX 78229, USA. Jennifer.allan@MHSHealth.com

Studies in Health Technology and Informatics
|September 14, 2004
PubMed
Summary

This study improved nursing risk assessments by embedding indicators into electronic systems, boosting accuracy and completeness. The new method reduced documentation queries and enhanced patient care planning.

Related Concept Videos

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Innovations in clinical simulation: Application of Benner's theory in an interactive patient care simulation.

Nursing education perspectives·2006
Same author

Using information technology to assist in redesign of a fall prevention program.

Journal of nursing care quality·2004
See all related articles

Area of Science:

  • Nursing Informatics
  • Health Information Systems
  • Clinical Documentation Improvement

Background:

  • Nursing assessments, particularly risk assessments, historically faced challenges with completeness and accuracy.
  • Previous software enhancements and education did not significantly improve risk assessment documentation between 1996 and 2001.
  • The 'paste' functionality in existing systems raised concerns about the accuracy of risk scoring.

Purpose of the Study:

  • To enhance the completeness and accuracy of nursing risk assessments.
  • To reduce nursing documentation queries.
  • To improve the accuracy of patient care plans based on risk assessments.

Main Methods:

  • Implemented a novel approach by embedding weighted risk assessment indicators directly into the nursing systems assessment.

Related Experiment Videos

  • Automated the calculation and display of risk scores.
  • Validated the results through concurrent manual review of skin and fall assessments.

    • Main Results:

    • Skin assessment accuracy reached 96% with 100% documentation completeness.
    • Fall assessment showed a 2.5% miss rate and 100% record completeness.
    • 100% of high-risk patients identified had appropriate care plan problems, demonstrating improved care plan accuracy.

    Conclusions:

    • Embedding indicators within nursing systems significantly decreases documentation queries.
    • This integrated approach enhances both the completeness and accuracy of nursing records.
    • Further exploration of embedded indicators in software design is recommended for future systems.