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Nursing clinical documentation data retrieval for hospitalized older adults with heart failure: part 2
Barbara J Head1, Cindy A Scherb, Meridean L Maas
1College of Nursing, University of Nebraska Medical Center in Omaha, Nebraska, USA. bhead@unmc.edu
Purpose:
The study aims to discuss the implications for retrieval of nursing data and building a multiorganizational data warehouse.
Methods:
The method used was a descriptive comparative multisite study of documented care for 302 older adults with heart failure. Unit and patient level variables were retrieved.
Findings:
Data regarding the most identified variables were retrievable electronically. Important linkages among nursing data elements were not present.
Conclusions:
Data were retrievable and the building of a data warehouse was possible and lessons were learned.
Implications:
When clinical information systems (CISs) are developed, developers and nurses must discuss how standardized data will be entered to ensure retrieval and usefulness in evaluating nursing care. For nursing effectiveness research, CISs must also provide linkages among nursing diagnoses and specific interventions, and nursing-sensitive patient outcomes.
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Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...