Retrieving Clinical Data and the Issues for Building Clinical Documentation Systems

2.50
Hdl Handle:
http://hdl.handle.net/10755/158733
Type:
Presentation
Title:
Retrieving Clinical Data and the Issues for Building Clinical Documentation Systems
Abstract:
Retrieving Clinical Data and the Issues for Building Clinical Documentation Systems
Conference Sponsor:Midwest Nursing Research Society
Conference Year:2009
Author:Scherb, Cindy, PhD, RN
P.I. Institution Name:Winona State University
Contact Address:4430 State Hwy 22, Kiester, MN, 56051, USA
Contact Telephone:507-290-3133
Co-Authors:C.A. Scherb, Winona State University, Rochester, MN; B. Head, , University of Nebraska Medical Center, Omaha, NE; M.L. Maas, S. Moorhead, M. Johnson, , University of Iowa, Iowa City, IA; D. Conley, , Nebraska Methodist Hospital and Nebraska Methodist Coll
Nursing effectiveness studies are few because it is only recently that hospital electronic clinical documentation systems have begun to include standardized languages that describe nursing problems, interventions and patient outcomes to enable the aggregation of data from multiple hospitals for analysis. The three hospital settings' documentation systems used for this pilot study included the North American Nursing Diagnosis International nursing diagnoses, Nursing Interventions Classification interventions, and Nursing Outcomes Classification outcomes. One purpose of this descriptive retrospective study and the focus of this presentation is to describe the process of data retrieval for all variables needed to evaluate the clinical and cost effectiveness of nursing interventions. The study focused on older persons, from the specific patient populations of pneumonia and heart failure, discharged between March 1, 2005 and February 28, 2006. Secondary clinical data (N=939) from three hospital sites, one in the Northeast and two in the Midwest, were used for analysis. Data elements collected were classified as either unit level variables (e.g., staff to patient ratio, staff skill mix, unit hours per patient day) or patient level variables (e.g., age, nursing diagnoses, nursing interventions, patient outcomes, nursing intensity, medical diagnoses, severity of illness, medications, discharge disposition, length of stay, number of readmissions). The researchers and data warehouse manager worked closely with nursing experts and data retrieval experts from each hospital site to retrieve all necessary variables. There was variability in the ability to retrieve all the data and in what format the data were available. This presentation will describe the lessons learned about data retrieval challenges such as 1) obtaining data from outside the clinical documentation systems; 2) variations in data formatting; and 3) missing data. Important issues in building information systems that will enable retrieval of elements useful for evidence based protocols and future effectiveness research will be discussed.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Midwest Nursing Research Society

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleRetrieving Clinical Data and the Issues for Building Clinical Documentation Systemsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/158733-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Retrieving Clinical Data and the Issues for Building Clinical Documentation Systems</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Midwest Nursing Research Society</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2009</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Scherb, Cindy, PhD, RN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Winona State University</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">4430 State Hwy 22, Kiester, MN, 56051, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">507-290-3133</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">cscherb@winona.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">C.A. Scherb, Winona State University, Rochester, MN; B. Head, , University of Nebraska Medical Center, Omaha, NE; M.L. Maas, S. Moorhead, M. Johnson, , University of Iowa, Iowa City, IA; D. Conley, , Nebraska Methodist Hospital and Nebraska Methodist Coll</td></tr><tr><td colspan="2" class="item-abstract">Nursing effectiveness studies are few because it is only recently that hospital electronic clinical documentation systems have begun to include standardized languages that describe nursing problems, interventions and patient outcomes to enable the aggregation of data from multiple hospitals for analysis. The three hospital settings' documentation systems used for this pilot study included the North American Nursing Diagnosis International nursing diagnoses, Nursing Interventions Classification interventions, and Nursing Outcomes Classification outcomes. One purpose of this descriptive retrospective study and the focus of this presentation is to describe the process of data retrieval for all variables needed to evaluate the clinical and cost effectiveness of nursing interventions. The study focused on older persons, from the specific patient populations of pneumonia and heart failure, discharged between March 1, 2005 and February 28, 2006. Secondary clinical data (N=939) from three hospital sites, one in the Northeast and two in the Midwest, were used for analysis. Data elements collected were classified as either unit level variables (e.g., staff to patient ratio, staff skill mix, unit hours per patient day) or patient level variables (e.g., age, nursing diagnoses, nursing interventions, patient outcomes, nursing intensity, medical diagnoses, severity of illness, medications, discharge disposition, length of stay, number of readmissions). The researchers and data warehouse manager worked closely with nursing experts and data retrieval experts from each hospital site to retrieve all necessary variables. There was variability in the ability to retrieve all the data and in what format the data were available. This presentation will describe the lessons learned about data retrieval challenges such as 1) obtaining data from outside the clinical documentation systems; 2) variations in data formatting; and 3) missing data. Important issues in building information systems that will enable retrieval of elements useful for evidence based protocols and future effectiveness research will be discussed.</td></tr></table>en_GB
dc.date.available2011-10-26T21:20:35Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T21:20:35Z-
dc.description.sponsorshipMidwest Nursing Research Societyen_GB
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