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. 2021 May 3;39(12):845-850.
doi: 10.1097/CIN.0000000000000736.

Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System

Min-Jeoung Kang  1 , Sarah Collins Rossetti, Christopher Knaplund, Frank Y Chang, Kumiko O Schnock, Kimberly Whalen, Emily J Gesner, Jose P Garcia, Kenrick D Cato, Patricia C Dykes
Affiliations

Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System

Min-Jeoung Kang et al. Comput Inform Nurs. .

Abstract

The purpose of this study was to demonstrate nursing documentation variation based on electronic health record design and its relationship with different levels of care by reviewing how various flowsheet measures, within the same electronic health record across an integrated healthcare system, are documented in different types of medical facilities. Flowsheet data with information on patients who were admitted to academic medical centers, community hospitals, and rehabilitation centers were used to calculate the frequency of flowsheet entries documented. We then compared the distinct flowsheet measures documented in five flowsheet templates across the different facilities. We observed that each type of healthcare facility appeared to have distinct clinical care foci and flowsheet measures documented differed within the same template based on facility type. Designing flowsheets tailored to study settings can meet the needs of end users and increase documentation efficiency by reducing time spent on unrelated flowsheet measures. Furthermore, this process can save nurses time for direct patient care.

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Figures

Figure 1.
Figure 1.
Comparison of flowsheet measures across three facilities
Figure 1.
Figure 1.
Comparison of flowsheet measures across three facilities
Figure 2.
Figure 2.
Counts of flowsheet measures recorded in five flowsheet templates commonly used among three facilities
See this image and copyright information in PMC

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