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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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Health records serve various essential purposes in the healthcare system. Here are some key purposes:
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Documentation of Nursing Diagnosis01:10

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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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Data Reporting and Recording01:24

Data Reporting and Recording

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Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
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Metrics for Electronic-Nursing-Record-Based Narratives: cross-sectional analysis.

Kidong Kim, Suyeon Jeong, Kyogu Lee

  • 1Soyeon Ahn, Ph.D., Division of Statistics, Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea,

Applied Clinical Informatics
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PubMed
Summary

Quantitative metrics from electronic nursing records reveal higher documentation for older patients, longer stays, and specific diagnoses like circulatory diseases. These metrics can describe hospital admissions and diagnoses consistently.

Keywords:
Electronic health recordsnarrative analysisnarrative evaluationnursing informaticsnursing records

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Area of Science:

  • Health Informatics
  • Nursing Informatics
  • Clinical Documentation Analysis

Background:

  • Electronic health records (EHRs) generate vast amounts of nursing narrative data.
  • Quantitative metrics derived from nursing narratives can offer insights into healthcare processes.
  • Understanding these metrics' characteristics is crucial for their effective utilization.

Purpose of the Study:

  • To characterize quantitative metrics of nursing narratives in electronic nursing records.
  • To associate these metrics with hospital admission traits and diagnoses.
  • To analyze a large dataset without pre-defined patient event or hypothesis limitations.

Main Methods:

  • Collected over 135 million structured, coded nursing narratives from nearly 231,500 hospital admissions.
  • Utilized data from patients discharged between 2008 and 2012 from a tertiary teaching institution.
  • Defined a standardized number of nursing narratives (narratives per day) to represent documentation frequency and quantity.

Main Results:

  • The standardized number of nursing narratives was significantly higher for patients aged 70 years and older.
  • Increased documentation frequency was observed in longer hospital stays (≥ 8 days) and cases of hospital death.
  • Higher narrative volumes were associated with admissions for "pregnancy, childbirth, and puerperium" and "diseases of the circulatory system".

Conclusions:

  • Quantitative metrics derived from nursing documents can consistently describe diverse hospital admissions and diagnoses.
  • Certain hospital admission areas may exhibit consistently increasing nursing documentation volumes over time.
  • Evaluating the usability of electronic nursing document metrics requires consideration of multiple hospital admission facets.