Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers?
J Wound Ostomy Continence Nurs
; 40(2): 157-62, 2013.
Article
em En
| MEDLINE
| ID: mdl-23466720
ABSTRACT
PURPOSE:
The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention.METHODS:
From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding.RESULTS:
The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001).CONCLUSIONS:
An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.
Texto completo:
1
Base de dados:
MEDLINE
Assunto principal:
Veteranos
/
Higiene da Pele
/
Pé Diabético
/
Registros Eletrônicos de Saúde
/
Controle de Formulários e Registros
Tipo de estudo:
Guideline
/
Observational_studies
/
Prognostic_studies
Limite:
Aged
/
Humans
/
Male
Idioma:
En
Ano de publicação:
2013
Tipo de documento:
Article