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Journal article
Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care
Computers, informatics, nursing, v 37(1)
01 Jan 2019
PMID: 30074919
Featured in Collection : UN Sustainable Development Goals @ Drexel
Abstract
Home care nurses have multiple goals at the patient admission visit. Electronic health records support some of these goals, including high-quality documentation, but nurses may not complete the electronic documentation at the point of care. To characterize admission nurses' practices at the point of care and lay the foundation for design recommendations, this study investigates admission nurses' documentation strategies with respect to entering electronic data and how nursing goals affect them. We conducted 10 observations of home care agency admissions with five admission nurses in rural Pennsylvania. We collected screenshots and recorded the admission process. We asked the nurses questions outside the point of care. We coded the nurses' strategies at the data-entry screen level. Using thematic analysis, we investigated the influence of nursing goals on documentation strategies. Subject matter experts reviewed our findings. Several goals affect nurses' documentation strategies: ensure data accuracy, reduce time in the patient's home, and prevent infection. Home care admission nurses distribute the electronic documentation temporally due to their goals. Nurses developed memory aids to support completion of the documentation after leaving the patients' homes. Design and training should support the distributed manner in which home care nurses document patient encounters.
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Details
- Title
- Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care
- Creators
- Yushi Yang - Drexel UniversityEllen J. Bass - University of PennsylvaniaKathryn H. Bowles - Visiting Nurse Service of New YorkPaulina S. Sockolow - Drexel Univ, Coll Nursing & Hlth Profess, Dept Hlth Syst & Sci Res, Philadelphia, PA 19104 USA
- Publication Details
- Computers, informatics, nursing, v 37(1)
- Publisher
- Lippincott Williams & Wilkins
- Number of pages
- 8
- Grant note
- R01HS024537 / Agency for Healthcare Research and Quality; United States Department of Health & Human Services; Agency for Healthcare Research & Quality
- Resource Type
- Journal article
- Language
- English
- Academic Unit
- Information Science; Civil, Architectural, and Environmental Engineering; Health Sciences Division
- Web of Science ID
- WOS:000455782700006
- Scopus ID
- 2-s2.0-85059797918
- Other Identifier
- 991019168223904721
UN Sustainable Development Goals (SDGs)
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- Collaboration types
- Domestic collaboration
- Web of Science research areas
- Computer Science, Interdisciplinary Applications
- Medical Informatics
- Nursing