A importância dos registros de enfermagem no faturamento hospitalar / The importance of nursing records in hospital billing

Objetivo: analisar a produção científica nacional sobre os registros de Enfermagem e sua relação direta com o faturamento hospitalar. Método: revisão integrativa, realizada em 20 artigos disponíveis on-line, no período de 2006 a 2016, nas bases de dados Medline, LILACS, BDEnf e na biblioteca SCIELO, analisados por meio de estatística descritiva simples, para a análise bibliométrica das produções encontradas, e da Análise de Conteúdo, para o aprofundamento da relação dos registros de Enfermagem com o faturamento hospitalar. Resultados: desta análise, emergiram as categorias temáticas "Ambiente Hospitalar e os Registros de Enfermagem"; "Auditoria de Enfermagem e o Faturamento Hospitalar" e "O profissional enfermeiro frente ao setor de auditoria". Conclusão: os registros de Enfermagem expressam a qualidade da assistência dispensada ao paciente, repercutem no faturamento da conta hospitalar, balizam a gestão no acompanhamento de indicadores de qualidade e viabilizam a manutenção financeira do serviço de saúde. Ressalta-se a importância da educação permanente acerca dos registros de Enfermagem e sua interface com a saúde financeira da organização de saúde.(AU)

Evaluating Business Value of IT in Healthcare: Three Clinical Practices from Australia and the US.

Exponentially increasing costs in healthcare coupled with poor quality and limited access have motivated the healthcare industry to turn to IS/IT solutions to overcome these issues and facilitate superior healthcare delivery. In an environment of rapid development of new clinical informatics solutions claiming to provide better healthcare delivery, there is a paucity of systematic frameworks to robustly measure the actual value of these systems. The promised business value of these solutions has been elusive; hence, this study offers an approach for the evaluation of the business value of health IS/IT solutions based on a conceptual model, which has been validated using three clinical case studies.

A nursing pilot study on bedside reporting to promote best practice and patient/family-centered care.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of bedside nursing report implementation on a pediatric neuroscience unit. BACKGROUND: The change-of-shift nursing report often involves only nurse-to-nurse communication, occurs far away from the patient's bedside, and includes little or no patient/family involvement. Studies show that the bedside nursing report is a more comprehensive and patient-centered approach (C. D. Anderson & R. R. Mangino, 2006). METHODS: Patient and nurse satisfaction and nursing overtime were measured 6 months before and 6 months after the implementation of bedside reporting. Data were analyzed using paired t test, chi-square test, and Fisher's exact tests to determine significant changes. RESULTS: Patients, families, and nurses reported an increase in satisfaction after the implementation of bedside reporting. Overtime decreased and represented a potential cost savings of nearly $13,000 annually. CONCLUSIONS: Bedside reporting saves money, improves patient and nurse satisfaction, and is a more comprehensive approach to change-of-shift reporting.

[Elzach concept and intervention catalogue of nursing therapy in postacute neurological rehabilitation within the German DRG System]. / Elzacher Konzept und Leistungskatalog der therapeutischen Pflege in der neurologischen Frührehabilitation (Phase B).

The German DRG system defines specialized treatments through a set of minimal requirements, the documentation of which and its assessment by external specialists of the medical service of the statutory health insurance causing frictions between rehabilitation hospitals and the medical service. It is especially problematic to make a clear distinction between nursing care and treatment. To reduce frictions and interface problems, a catalogue of acts of therapy performed by nurses was agreed for neurological early rehabilitation in Baden-Württemberg. This Elzach concept and catalogue describe therapeutic nursing in neurological rehabilitation and increase transparency and accountability both for providers and cost carriers.

A importância das anotações de enfermagem nas glosas hospitalares / La importancia de las notas de enfermería en glosas hospitalares / The importance of nursing notes on hospital glosses

A auditoria iniciou seu foco na área contábil com controle de custos. Porém, a auditoria sofreu uma mudança de paradigma e,atualmente, é uma ferramenta de apoio à gestão, buscando a excelência em aspectos técnicos, administrativos, éticos e legais. Asanotações de enfermagem, neste contexto, são alvo de auditorias nos serviços de saúde devido à representação de todo o cuidadoprestado ao paciente, além de sua importância para os custos hospitalares e as glosas. Este estudo teve a intenção de verificar,através da revisão da literatura nacional publicada no período de 2000 a 2010, a importância e os fatores intervenientes nasanotações de enfermagem para as glosas hospitalares. Foi possível identificar a importância dos registros de enfermagem e como asanotações de enfermagem contribuem para as glosas hospitalares. Sugere-se uma nova forma de gestão hospitalar junto aoenfermeiro auditor, equipes de educação continuada e a utilização da Sistematização da Assistência de Enfermagem para uma melhorqualificação do cuidado e excelência em enfermagem, além da diminuição do número de glosas nas instituições hospitalares.

The audit began focused on accounting with control of costs. However with a change of concept is now a tool to support management,striving for excellence in technical, administrative, ethical and legal aspects. Nursing notes are subject to audit in health services dueto the representation of all patient care. This study was intended to check through the literature review, the importance of thenursing glosses in hospitals and found that they contribute greatly in this and reinforces the importance of new hospital managementtechnics with the nurse auditor, continuing education and the use of Nursing Care Systematization for the qualification and excellencein nursing.

La auditoría empezó su enfoque en la contabilidad, el control de costes mas sufrió un cambio de paradigma en lo que hoy es unaherramienta para apoyar la gestión, búsqueda de la excelencia en los aspectos técnicos, administrativos, éticos y legales. Las notasde enfermería están sujetos a la auditoría de los servicios de salud debido a la representación de todos el cuidado del paciente. Esteestúdio fue deseñado para verificar a través de la revisión de la literatura, la importância de las glosas de enfermeira em el hospotaly encontró que contribuyen em gran medida em las glosas y refuerza la importancia de um nuevo modelo de gestión com el auditorenfermeira, educación continua y el uso del Sistema de Cuidado de Enfermería para la calificación y la excelência em enfermeira.

Point-of-care technology supports bedside documentation.

As the conversion to an electronic health record intensifies, the question of which data-entry device works best in what environment and situation is paramount. Specifically, what is the best mix of equipment to purchase and install on clinical units based on staff preferences and budget constraints? The authors discuss their evaluation of stationary personal computers, workshops on wheels, and handheld tablets related to timeliness of data entry and their use of focus groups to ascertain the pros/cons of data-entry devices and staff preferences. An assessment of the implications for costs related to the timeliness of data entry is also presented.

[Efficiency of computer-based documentation in long-term care--preliminary project]. / Effizienz der computergestültzten Dokumentation in Pflegeheimen--eine Pilotstudie.

In Germany the documentation of processes in long-term care is mainly paper-based. Planning, realization and evaluation are not supported in an optimal way. In a preliminary study we evaluated the consequences of the introduction of a computer-based documentation system using handheld devices. We interviewed 16 persons before and after introducing the computer-based documentation and assessed costs for the documentation process and administration. The results show that reducing costs is likely. The job satisfaction of the personnel increased, more time could be spent for caring for the residents. We suggest further research to reach conclusive results.

[Electronic medical records should be structured]. / Elektroniske pasientjournaler bør vaere strukturerte.

BACKGROUND: Use of information technology in the health services has not resulted in the benefits hoped for. An important prerequisite for success may be to structure electronic medical records. Is this assumption research-based? MATERIAL AND METHODS: PubMed was searched via Endnote. The search words "medical record (any field) + structured (any field)" resulted in 843 hits and "electronic decision support (any field)" resulted in 824. Titles and abstracts were used to identify relevant articles; titles identified 103 articles and abstracts 70. RESULTS: Research shows that structured electronic medical records can result in quicker data entry, improved quality and records that are useful in daily clinical work. Doctors and nurses prefer structured data entry; electronic nursing records are better and databases with structured electronic patient records can be used on a large scale to develop treatment regimes and quality assurance. Clinical decision support systems integrated into electronic medical records can provide positive cost-effectiveness. Most doctors and nurses understand the importance of such systems. INTERPRETATION: Structured data entry seems to be an important element in successful electronic medical record systems.

[Patient classification systems. Nursing workload from the perspective of applied research (part I)]. / Patientenklassifikationssysteme. Leistungsdaten im Blickfeld angewandter Forschung (Teil 1).

This article describes in two parts the basic principles of categorising nursing data into Patient Classification Systems (PCS) and related findings of nursing research. PCS are used to group patients into classes by using some specified criteria or indicators, e.g. needs of a patient, functional status or different nursing activities. They are often applied to constitute staff requirements. Since the large number of available classification systems differs in terms of development procedures and use of resulting data, it was rarely possible to compare different PCS with each other until now. Therefore a typology of PCS was developed, which is presented in the first part of this article. While assigning current PCS to adequate classes of the typology, the development and complexity of different PCS can be evaluated and discussed. Thus using the typology allows to identify advantages and limitations of individual classification systems. Conclusions can be drawn about requirements for further PCS development.