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Nursing Record Innovations Aimed at Harmonizing Structured Clinical Knowledge Among Doctors and Nurses.

Satoko Tsuru¹, Tetsuro Tamamoto², Hitoshi Furuya²

¹The University of Tokyo.

Studies in Health Technology and Informatics

|June 24, 2020

Summary

Hospital expenses are high in Japan, impacting hospital management. This study improved nurse record-keeping using the Patient Condition Adaptive Path System (PCAPS) and Team Compass application, enhancing collaboration and efficiency.

Keywords:

digitalization healthcare quality management structured clinical knowledge

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Area of Science:

Healthcare Management
Clinical Informatics
Nursing Informatics

Background:

Hospitalization expenses constitute a significant portion of Japan's national medical expenditure, reaching 36.8% in 2015.
Nurse labor costs represent approximately one-fifth of general hospital expenditures, highlighting their substantial impact on hospital management.
Current nurse record-keeping is time-consuming and of poor quality, necessitating improvements in accessibility and efficiency.

Purpose of the Study:

To enhance nurse record-keeping processes for improved accessibility and reduced time spent on documentation.
To harmonize structured clinical knowledge between physicians and nurses.
To streamline the creation of foundational nursing plans through interdisciplinary collaboration.

Main Methods:

Development of 778 Patient Condition Adaptive Path System (PCAPS) items across all clinical departments.
Integration of PCAPS content with the "Team Compass" application for standardized sharing among hospitals.
Linking electronic medical records with Team Compass to summarize clinical progress sheets and clinical orders.

Main Results:

Successful summarization of clinical progress sheet information by linking electronic medical records and Team Compass.
Facilitation of collaborative foundational nursing plan creation by enabling smooth information sharing between nurses and doctors.
Implementation of Team Compass in May 2019, with PCAPS-based care pathways used for 580 inpatients on the first day.

Conclusions:

The Team Compass system, utilizing PCAPS, effectively improved nurse record-keeping processes and interdisciplinary collaboration.
The system demonstrated successful integration and adoption, treating approximately 4,000 patients between May and August 2019 without major issues.
This approach offers a viable solution for reducing hospitalization expenses by optimizing nursing workflows and enhancing clinical knowledge harmonization.