Pain process of patients with cardiac surgery-Semantic annotation of electronic patient record data.

AIMS AND OBJECTIVES: To describe and compare the pain process of the patients' with cardiac surgery through nurses' and physicians' documentations in the electronic patient records. BACKGROUND: Postoperative pain assessment and management should be documented regularly, to ensure optimal pain care process for patients. Despite availability of evidence-based guidelines, pain assessment and documentation remain inadequate. DESIGN: A retrospective patients' record review. METHODS: The original data consisted of the electronic patient records of 26,922 patients with a diagnosed heart disease. A total of 1,818 care episodes of patients with cardiac surgery were selected from the data. We used random sampling to obtain 280 care episodes for annotation. These 280 care episodes contained 2,156 physician reports and 1,327 days of nursing notes. We developed an annotation manual and schema, and then, we manually conducted semantic annotation on care episodes, using the Brat annotation tool. We analysed the annotation units using thematic analysis. Consolidated criteria for reporting qualitative research guideline was followed in reporting where appropriate in this study design. RESULTS: We discovered expressions of six different aspects of pain process: (a) cause, (b) situation, (c) features, (d) consequences, (e) actions and (f) outcomes. We determined that five of the aspects existed chronologically. However, the features of pain were simultaneously existing. They indicated the location, quality, intensity, and temporality of the pain and they were present in every phase of the patient's pain process. Cardiac and postoperative pain documentations differed from each other in used expressions and in the quantity and quality of descriptions. CONCLUSION: We could construct a comprehensive pain process of the patients with cardiac surgery from several electronic patient records. The challenge remains how to support systematic documentation in each patient. RELEVANCE TO CLINICAL PRACTICE: The study provides knowledge and guidance of pain process aspects that can be used to achieve an effective pain assessment and more comprehensive documentation.

Immunotherapy Toxicities: 
A New Electronic Documentation Template to Improve Patient Care.

BACKGROUND: Emerging immunotherapies are associated with numerous toxicities. Although traditional health records allow nurses to document system-based assessments, few offer immunotherapy-based documentation templates to assess and grade toxicities.
. OBJECTIVES: The aim of this article is to present the development of a standardized template for documenting genetically modified cellular product-related toxicities in an electronic health record (EHR).
. METHODS: Through interprofessional collaboration, a documentation template for genetically modified cellular product-related toxicities was developed in an EHR, allowing for standardized documentation, data reporting, and tracking of immune-related toxicities. 
. FINDINGS: The documentation template has enhanced the quality and safety of practice at the authors' institution and provides a framework for other nursing units when initiating immunotherapy care.
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Drug supply in in-patient nursing care facilities: reasons for irregularities in quality reviews / Medikamentenversorgung durch stationäre Pflegeeinrichtungen: Gründe für Auffälligkeiten in Qualitätsprüfungen

Background: Quality checks of the independent German Health Insurance Medical Service in in-patient nursing care facilities pursuant to Articles 114 et seqq. SGB XI [11th Book of the Social Code] also comprise the Pflegerische Medikamentenversorgung (PMV) [drug supply by nursing personnel]. Irregularities are described in quality reports in the reviewer's own words. This investigation was intended to categorise the reasons for the above irregularities. Methods: The bases for the examination are the reports of quality checks of all of in-patient nursing care facilities conducted in 2014 (regular quality checks) in Hamburg and Schleswig-Holstein (N = 671), in which the PMV was examined for 5 742 randomly selected residents. Results: With regard to the documentation, inexplicable drug intakes (5.8 %) were found most frequently, followed by missing information on dosages and application provisions (0.8 % each), which were registered as irregularities at the residents. In the documentation of on-demand medication, insufficient indication data (3.2 %), missing daily maximum dosages (0.8 %) and missing single doses (0.6 %) were most commonly ascertained. The most frequent reasons for medication handling irregularities for the residents were false positioning (6.0 %), missing and respectively false data on consumption and on when the medical packaging was opened (3.5 %), as well as medication not directly administered using the blister (0.7 %). As for subordinate classifications of false positioning, incorrect dosages were revealed most often, followed by drugs with an exceeded expiry date and by out-of-stock drugs. Systematic patient-related factors with influence on PMV could not be determined. Conclusions: The extent of the irregularities and their type prompt a further increase in the efforts to improve the quality of nursing care facilities. The results can be used as a basis for designing specific initiatives to improve the PMV.

An educational intervention impact on the quality of nursing records / Impacto de uma intervenção educativa na qualidade dos registros de enfermagem / Impacto de una intervención educativa en la calidad de los anotaciones de enfermería

ABSTRACT Objective: to evaluate the impact of an educational intervention on the quality of nursing records. Method: quasi-experimental study with before-and-after design conducted in a hospital. All the nurses in the cardiac intensive care unit of the hospital received the intervention, which consisted of weekly meetings during five months. To collect data, the instrument Quality of Diagnoses, Interventions and Outcomes was applied to the patients' charts in two moments: baseline and after intervention. Results: the educational intervention had an impact on the quality of the records, since most of the items presented a significant increase in their mean values after the intervention, despite the low values in the two moments. Conclusion: the educational intervention proved to be effective at improving the quality of nursing records and a lack of quality was identified in the evaluated records, revealed by the low mean values and by the weakness of some questions presented in the items, which did not present a significant increase. Therefore, educational actions focused on real clinical cases may have positive implications for nursing practice.

RESUMO Objetivo: avaliar o impacto de uma intervenção educativa na qualidade dos registros de enfermagem. Método: trata-se de ensaio quase experimental do tipo antes e depois, realizado em instituição hospitalar. Todas as enfermeiras da unidade de terapia intensiva cardiológica do hospital em questão receberam a intervenção composta de sessões semanais, durante cinco meses. Para a coleta de dados, nos prontuários dos pacientes, foi utilizado o instrumento Quality of Diagnoses, Interventions and Outcomes, aplicado em dois momentos, basal e após intervenção. Resultados: a intervenção educativa teve efeito na qualidade dos registros, visto que a maioria dos itens teve aumento significativo nos seus valores médios, após a intervenção, apesar de médias baixas dos itens para os dois momentos. Conclusão: demonstrou-se a efetividade da intervenção para a melhora da qualidade dos registros de enfermagem, bem como evidenciou-se a falta de qualidade dos registros avaliados, revelada pelos baixos valores de média e, ainda, a fragilidade de algumas questões apresentadas em itens, as quais não obtiveram aumento significativo. Assim, ações educativas, com foco em casos reais, podem ter implicações positivas para a prática de enfermagem.

RESUMEN Objetivo: evaluar el impacto de una intervención educativa en la calidad de las anotaciones de enfermería. Método: se trata de un estudio cuasi-experimental del tipo antes y después, realizado en una institución hospitalaria. Todas las enfermeras de la unidad de cuidados intensivos de cardiologia del hospital en cuestión recibieron la intervención compuesta por sesiones semanales, durante cinco meses. Para la recolección de datos de las historias clinicas de los pacientes, se utilizó el instrumento Quality of Diagnoses, Interventions and Outcomes (Calidad de Diagnósticos, Intervenciones y Resultados), aplicado en dos momentos, basal y pos-intervención. Resultados: la intervención educativa causó efecto en la calidad de las anotaciones, visto que la mayoría de los ítems aumentó significativamente los valores medios posteriores a la intervención, a pesar de los promedios bajos de los ítems en los dos momentos. Conclusión: se demostró la efectividad de la intervención para mejorar la calidad de las anotaciones de enfermería y se evidenció la falta de calidad de las anotaciones evaluadas, revelada por los valores bajos del promedio y la fragilidad de algunas preguntas presentadas en los ítems, las cuales no obtuvieron un aumento significativo. Por eso, acciones educativas, con enfoque en casos reales, pueden impactar positivamente en la práctica de enfermería.

Standardized Nursing Data and the Oncology Nurse.

Oncology nurses are experts in conducting comprehensive assessments of symptoms and patient responses to treatments, but documentation in electronic health records frequently results in data that cannot be readily shared or compared because of a lack of standardization of the terms. Standardized nursing terminology can enhance communication among nurses and between nurses and other members of the healthcare team. It can improve care coordination and may enable nurses to capture and make visible the unique, holistic perspective that they provide to patient care. Standardization also is important for large-scale data aggregation, which will enable healthcare teams to learn about particular subsets of patients so that care can be tailored to individual characteristics and responses.

Evaluation of Nursing Documentation Completion of Stroke Patients in the Emergency Department: A Pre-Post Analysis Using Flowsheet Templates and Clinical Decision Support.

The primary aim of this performance improvement project was to determine whether the electronic health record implementation of stroke-specific nursing documentation flowsheet templates and clinical decision support alerts improved the nursing documentation of eligible stroke patients in seven stroke-certified emergency departments. Two system enhancements were introduced into the electronic record in an effort to improve nursing documentation: disease-specific documentation flowsheets and clinical decision support alerts. Using a pre-post design, project measures included six stroke management goals as defined by the National Institute of Neurological Disorders and Stroke and three clinical decision support measures based on entry of orders used to trigger documentation reminders for nursing: (1) the National Institutes of Health's Stroke Scale, (2) neurological checks, and (3) dysphagia screening. Data were reviewed 6 months prior (n = 2293) and 6 months following the intervention (n = 2588). Fisher exact test was used for statistical analysis. Statistical significance was found for documentation of five of the six stroke management goals, although effect sizes were small. Customizing flowsheets to meet the needs of nursing workflow showed improvement in the completion of documentation. The effects of the decision support alerts on the completeness of nursing documentation were not statistically significant (likely due to lack of order entry). For example, an order for the National Institutes of Health Stroke Scale was entered only 10.7% of the time, which meant no alert would fire for nursing in the postintervention group. Future work should focus on decision support alerts that trigger reminders for clinicians to place relevant orders for this population.

Use of Electronic Nurse Reminders to Improve Documentation: A Process Improvement for a Comprehensive Stroke Center.

Nurses on a neurological step-down unit were challenged to switch from documenting assessments by hand to documenting by using a highly technological, electronic format. Upon the switch to electronic documentation, it was discovered through a chart audit that neurological assessments were not being documented properly. The purpose of this project was to implement Care Organizer, an electronic nurse reminder tool, on a neurological step-down unit and to evaluate the tool's ability to assist RNs in documentation of neurological assessments. Fifty patients' charts were audited for documentation of neurological assessments. Thirty-two RNs completed an anonymous demographic survey and were provided with eight training sessions related to utilization of Care Organizer. The RNs were asked to complete an evaluation of the tool 2 weeks after training and again at 1 month after training. A second chart audit was conducted at 1 month to assess for improvement of documentation 1 month after training. Preimplementation/postimplementation chart audits revealed improvements in documentation of neurological assessments in seven of eight criteria examined. Nurses admitted discomfort with Care Organizer and verbalized concerns that it was not convenient and/or user-friendly. Most admitted that with collaboration between information technology department and nursing, the tool could be further developed to become more applicable to nurses.

Usability of the Clinical Care Classification System for Representing Nursing Practice According to Specialty.

This study examined the ability of the Clinical Care Classification system to represent nursing record data across various nursing specialties. The data comprised nursing care plan records from December 1998 to October 2008 in a medical center. The total number of care plan documentation we analyzed was 2 060 178, and we used a process of knowledge discovery in datasets for data analysis. The results showed that 75.42% of the documented diagnosis terms could be mapped using the Clinical Care Classification system. However, a difference in nursing terminology emerged among various nursing specialties, ranging from 0.1% for otorhinolaryngology to 100% for colorectal surgery and plastic surgery. The top five nursing diagnoses were identified as knowledge deficit, acute pain, infection risk, falling risk, and bleeding risk, which were the most common health problems in an acute care setting but not in non-acute care settings. Overall, we identified a total of 21 established nursing diagnoses, which we recommend adding to the Clinical Care Classification system, most of which are applicable to emergency and intensive care specialties. Our results show that Clinical Care Classification is useful for documenting patient's problems in an acute setting, but we suggest adding new diagnoses to identify health problems in specialty settings.

Electronic medical record in the simulation hospital: does it improve accuracy in charting vital signs, intake, and output?

Nursing care delivery has shifted in response to the introduction of electronic health records. Adequate education using computerized documentation heavily influences a nurse's ability to navigate and utilize electronic medical records. The risk for treatment error increases when a bedside nurse lacks the correct knowledge and skills regarding electronic medical record documentation. Prelicensure nursing education should introduce electronic medical record documentation and provide a method for feedback from instructors to ensure proper understanding and use of this technology. RN preceptors evaluated two groups of associate degree nursing students to determine if introduction of electronic medical record in the simulation hospital increased accuracy in documenting vital signs, intake, and output in the actual clinical setting. During simulation, the first group of students documented using traditional paper and pen; the second group used an academic electronic medical record. Preceptors evaluated each group during their clinical rotations at two local inpatient facilities. RN preceptors provided information by responding to a 10-question Likert scale survey regarding the use of student electronic medical record documentation during the 120-hour inpatient preceptor rotation. The implementation of the electronic medical record into the simulation hospital, although a complex undertaking, provided students a safe and supportive environment in which to practice using technology and receive feedback from faculty regarding accurate documentation.

Continuity of care with HL7 v3 care record for oncology nursing.

UNLABELLED: The Clinical Data Ware House needs to meet three functions: reporting quality indicators, clinical research, and continuity of care. This paper reports on one function, namely the development and testing of data exchange for continuity of nursing care for oncology patients. The proof of principle was carried out using system analysis, requirements setting, system design, system development and experiment with the application of Health Level 7 version 3 Care Record electronic message. A successful testing of the Care Record message was conducted, using a case based data-subset for oncology nursing care including personal data, pain, weight and vital signs, among others. CONCLUSION: The development illustrated that the system components facilitate electronic data exchange from hospital to home care, allowing home care nurses to use received clinical data in their local system. In an incremental approach this data exchange can be enhanced to meet all data and all systems requirements.