Essential Documentation Elements: Quality Tool for the Emergency Department Nurse.
The use of real-time feedback about documentation may improve compliance with best practice standards, provide immediate rewards for high-quality documentation, and present an opportunity to make instantaneous improvements to the documentation. This project was conducted in a large, urban emergency...
| Publicado en: | Advanced Emergency Nursing Journal Vol. 36; no. 2; pp. 199 - 206 |
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| Autores principales: | , , |
| Formato: | pictorial research tables/charts Journal Article |
| Publicado: |
Lippincott Williams & Wilkins
Apr-Jun2014
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=96299057&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 96299057 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 19314485 2WNI jtl: Advanced Emergency Nursing Journal issn: 19314485 maglogo: N pubinfo: dt: Apr-Jun2014 vid: 36 iid: 2 pid: 5086 pub: Lippincott Williams & Wilkins place: Baltimore, Maryland artinfo: ui: 96299057 96299057 107854235 10.1097/TME.0000000000000020 96299057 ppf: 199 ppct: 7 formats: tig: atl: Essential Documentation Elements: Quality Tool for the Emergency Department Nurse. aug: au: Nielsen, Gayla Peschel, Laura Burgess, Ann affil: Emergency Department, Cedars-Sinai Medical Center, Los Angeles, California sug: subj: Emergency Service Information Systems Patient Record Systems Nursing Records Charting Nursing Care Emergency Nursing Professional Compliance Quality Improvement Emergency Service Feedback Cues Software Design Nursing Outcomes Registered Nurses Nursing Audit Record Review Convenience Sample Descriptive Statistics User-Computer Interface Nursing Staff, Hospital Quality of Care Research Human ab: The use of real-time feedback about documentation may improve compliance with best practice standards, provide immediate rewards for high-quality documentation, and present an opportunity to make instantaneous improvements to the documentation. This project was conducted in a large, urban emergency department (ED) to enhance patient safety, improve documentation quality, and increase timeliness of documentation. The PDSA (Plan, Do, Study, Act) model was used to develop a valid and reliable process to enhance the clinical care process. Passive electronic visual cues with real-time feedback to the clinician were developed. Between March 2011 and 2012, a total of 89,521 ED records were reviewed for compliance with 16 documentation elements. Documentation improvements were achieved with seven elements. There was a slight decrease in compliance for four elements, and equivalent levels of compliance in five elements were noted. Staff reported that the program was helpful in providing reminders and that passive cues were more helpful than hard stops. Areas for software refinement were also identified. This process demonstrated that the data collection burden was reduced and sampling error was eliminated. Although additional study is needed, the electronic health record can provide passive visual cues to enhance nursing care, improve regulatory compliance and data collection, and provide immediate feedback to the clinician. pubtype: Academic Journal doctype: pictorial research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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