Relationship between nursing documentation and patients' mortality.

Area of Science:

• Nursing Informatics
• Clinical Data Mining
• Patient Outcomes Research

Background:

• Nurses' monitoring behavior changes with patient deterioration.
• Optional nursing documentation may indicate patient concern.
• Electronic health record (EHR) data mining can predict mortality.

Purpose of the Study:

• To test if optional nursing documentation in EHRs predicts patient mortality.
• To analyze the association between nursing documentation patterns and patient outcomes.

Main Methods:

• Data mining of EHR nursing documentation over 15 months.
• Analysis of mortality rates and documentation frequency (vital signs, comments).
• Stratification by age-adjusted Charlson comorbidity index.

Main Results:

• Died patients had more optional comments and vital sign documentation than survivors.
• Increased documentation frequency correlated with higher cardiac arrest likelihood.
• More documented comments in cardiac arrest patients predicted higher mortality.

Conclusions:

• Nursing documentation patterns are linked to patient mortality.
• EHR nursing documentation features can predict mortality.
• Future work could use these associations for real-time risk assessment.