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Patients' needs assessment documentation in multidisciplinary electronic health records
Kristiina Häyrinen1, Kaija Saranto
1Department of Health and Social Management, University of Eastern Finland, Kuopio Campus, Finland. kristiina.hayrinen@uef.fi
Studies in Health Technology and Informatics
|September 16, 2010
Summary
Physicians and nurses document patient needs differently in electronic health records (EHR). Nursing documentation, using the Finnish Classification of Nursing Diagnoses (FiCND), offers more detailed patient needs assessment.
Area of Science:
- Medical Informatics
- Nursing Informatics
- Health Information Management
Background:
- Patient needs assessment is crucial for care planning, implementation, and evaluation.
- Physicians and nurses collect and interpret patient data during care.
- Accurate documentation in electronic health records (EHR) is essential for effective patient care.
Purpose of the Study:
- To describe and discuss physicians' and nurses' documentation of patient needs assessment in EHR within neurological care.
- To compare the documentation practices of physicians and nurses regarding patient needs.
- To evaluate the impact of standardized documentation on data quality and retrieval.
Main Methods:
- Analysis of 48 neurological medical narratives and nursing care plans.
- Descriptive statistics and content analysis were employed.
- Examination of documentation content, including referrals, consultations, anamnesis, and status praesens.
Main Results:
- Physician documentation includes referrals and consultations, detailing the reason for care, medical history, and current status.
- Nurse documentation utilizes the Finnish Classification of Nursing Diagnoses (FiCND) and narrative text for needs assessment.
- Physician and nurse documentation were found to be complementary, with nursing documentation providing more granular detail due to FiCND use.
Conclusions:
- The use of standardized documentation, such as FiCND, enhances the quality and retrievability of patient data in EHR.
- Complementary documentation by physicians and nurses provides a comprehensive view of patient needs.
- Improved documentation practices can lead to better-informed care decisions in neurological settings.
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