Developing and testing a prototype patients care database

Area of Science:

• Health Informatics
• Nursing Informatics
• Data Management in Healthcare

Background:

• Effective patient care management relies on robust information systems.
• Existing methods for capturing nursing data present challenges in comprehensive analysis.
• Developing standardized databases is crucial for quality improvement initiatives.

Purpose of the Study:

• To develop and evaluate a database for managing patient care information.
• To assess the feasibility of capturing nursing data retrospectively.
• To identify patient problems, nursing interventions, and outcome achievement.

Main Methods:

• Retrospective review of medical records for 67 patients.
• Data extraction categorized into patient problems, nursing interventions, and outcome achievement.
• Analysis of documented patient outcomes against expected outcomes.

Main Results:

• Identified 439 patient problems and 4541 nursing interventions.
• Assessment and surveillance activities comprised 26% of all nursing interventions.
• Only 55% of 2326 identified patient outcomes were documented as met.

Conclusions:

• The developed database provides a framework for managing patient care information.
• Significant gaps exist in the documentation of patient outcome achievement.
• The database has potential for outlier analysis and outcomes assessment in specific patient populations.