Differences in documentation completeness among nursing units before and after computerization

2.50
Hdl Handle:
http://hdl.handle.net/10755/148518
Type:
Presentation
Title:
Differences in documentation completeness among nursing units before and after computerization
Abstract:
Differences in documentation completeness among nursing units before and after computerization
Conference Sponsor:Sigma Theta Tau International
Conference Year:1999
Author:Larrabee, June, PhD
P.I. Institution Name:Robert C. Byrd Health Sciences Center of West Virginia University
Title:Associate Professor
Objective, hypothesis, or aims: Nurses face strong incentives to demonstrate that quality nursing care has a positive influence on patient outcomes. For decades, the patient record has been a key data source for evaluating healthcare quality and patient outcomes despite the findings of numerous studies that such data are of questionable validity. Computerization is an increasingly pervasive approach to improving validity of patient record data. Nursing process has long been a tool used to guide patient outcomes focused care. No studies were located that evaluated documentation completeness of patient outcomes assessment among nursing units before and after implementation of a computerized Nursing Information System (NIS). A new model of quality proposes a relationship between the quality of care given (quality) and patient outcomes (beneficence). Preliminary to investigating this relationship, this study evaluated nursing documentation completeness of patient outcomes assessment among nursing units one month prior to (Time 1) and six months after (Time 2) NIS implementation. This study also evaluated nursing documentation completeness of patient outcomes assessment among nursing units before (Times 1 and 2) and after (Time 3) staff re-education in using the NIS to document care.

Design: Time series design with three time points

Sample Population (subjects): Closed records of hospitalized adult patients

Data Collection Sites (settings): The study site was a 100-bed university hospital located in west Tennessee. A stratified sample of closed records was randomly selected based on percent of admissions for each of three nursing units at three time points (August 1995, April 1996, April 1997). The combined sample consisted of a minimum of 90 records at each time point.

Name(s) of Concepts or Variables Studied Together (separated by commas): patient outcomes assessment (PTASSESS)

Instruments/Measurements: chart review form

Findings: The mean PTASSESS scores for the nursing units at Time 1 (Unit 1, 66.7 ± 36.8; Unit 2, 84.5 ± 28; Unit 3, 86.9 ± 29.9), Time 2 (Unit 1, 61.4 ± 27.9; Unit 2, 63.6 ± 23.6; Unit 3, 43.1 ± 27.5), and Time 3 (Unit 1, 91.6 ± 14; Unit 2, 71 ± 20.5; Unit 3, 67.1 ± 30.1) were significantly different (p < 0.04).

Conclusions: Nursing documentation of patient outcomes assessment differed among the three units at each time point. Furthermore, the mean score on each unit was lower at six months after implementation of a computerized NIS than before. But, this documentation did improve on each unit after re-education of nurses in the use of the NIS.

Clinical Implications: Failure to document assessment of patient outcomes limits the recorded data available about patient outcomes. Nurses implementing computerized documentation must evaluate documentation completeness before and at periodic intervals after implementation. Evaluation results should be used to continuously improve documentation completeness, thereby improving patient record data validity. Improvement strategies should consider unit differences in documentation scores. Demonstrated data validity is a pre-requisite to using patient record data to investigate the influence of nursing care quality on patient outcomes.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Sigma Theta Tau International

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleDifferences in documentation completeness among nursing units before and after computerizationen_GB
dc.identifier.urihttp://hdl.handle.net/10755/148518-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Differences in documentation completeness among nursing units before and after computerization</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Sigma Theta Tau International</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">1999</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Larrabee, June, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Robert C. Byrd Health Sciences Center of West Virginia University</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Associate Professor</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">jlarrabe@hsc.wvu.edu</td></tr><tr><td colspan="2" class="item-abstract">Objective, hypothesis, or aims: Nurses face strong incentives to demonstrate that quality nursing care has a positive influence on patient outcomes. For decades, the patient record has been a key data source for evaluating healthcare quality and patient outcomes despite the findings of numerous studies that such data are of questionable validity. Computerization is an increasingly pervasive approach to improving validity of patient record data. Nursing process has long been a tool used to guide patient outcomes focused care. No studies were located that evaluated documentation completeness of patient outcomes assessment among nursing units before and after implementation of a computerized Nursing Information System (NIS). A new model of quality proposes a relationship between the quality of care given (quality) and patient outcomes (beneficence). Preliminary to investigating this relationship, this study evaluated nursing documentation completeness of patient outcomes assessment among nursing units one month prior to (Time 1) and six months after (Time 2) NIS implementation. This study also evaluated nursing documentation completeness of patient outcomes assessment among nursing units before (Times 1 and 2) and after (Time 3) staff re-education in using the NIS to document care.<br/><br/>Design: Time series design with three time points<br/><br/>Sample Population (subjects): Closed records of hospitalized adult patients<br/><br/>Data Collection Sites (settings): The study site was a 100-bed university hospital located in west Tennessee. A stratified sample of closed records was randomly selected based on percent of admissions for each of three nursing units at three time points (August 1995, April 1996, April 1997). The combined sample consisted of a minimum of 90 records at each time point.<br/><br/>Name(s) of Concepts or Variables Studied Together (separated by commas): patient outcomes assessment (PTASSESS)<br/><br/>Instruments/Measurements: chart review form<br/><br/>Findings: The mean PTASSESS scores for the nursing units at Time 1 (Unit 1, 66.7 &plusmn; 36.8; Unit 2, 84.5 &plusmn; 28; Unit 3, 86.9 &plusmn; 29.9), Time 2 (Unit 1, 61.4 &plusmn; 27.9; Unit 2, 63.6 &plusmn; 23.6; Unit 3, 43.1 &plusmn; 27.5), and Time 3 (Unit 1, 91.6 &plusmn; 14; Unit 2, 71 &plusmn; 20.5; Unit 3, 67.1 &plusmn; 30.1) were significantly different (p &lt; 0.04).<br/><br/>Conclusions: Nursing documentation of patient outcomes assessment differed among the three units at each time point. Furthermore, the mean score on each unit was lower at six months after implementation of a computerized NIS than before. But, this documentation did improve on each unit after re-education of nurses in the use of the NIS.<br/><br/>Clinical Implications: Failure to document assessment of patient outcomes limits the recorded data available about patient outcomes. Nurses implementing computerized documentation must evaluate documentation completeness before and at periodic intervals after implementation. Evaluation results should be used to continuously improve documentation completeness, thereby improving patient record data validity. Improvement strategies should consider unit differences in documentation scores. Demonstrated data validity is a pre-requisite to using patient record data to investigate the influence of nursing care quality on patient outcomes.</td></tr></table>en_GB
dc.date.available2011-10-26T09:46:21Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T09:46:21Z-
dc.description.sponsorshipSigma Theta Tau Internationalen_GB
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