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Documentation Systems (documentation + system)
Selected AbstractsUsing an Electronic Medical Documentation System to Track Patient Safety InitiativesJOURNAL OF OBSTETRIC, GYNECOLOGIC & NEONATAL NURSING, Issue 2010Professional Issues No abstract is available for this article. [source] Chief Complaints, Emergency Department Clinical Documentation Systems, and the Challenge of Dealing with the Patient's Own WordsACADEMIC EMERGENCY MEDICINE, Issue 1 2007Gregg Husk MD First page of article [source] Implementation of Standardized Nomenclature in the Electronic Medical RecordINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 4 2009Joan Klehr RNC MPH PURPOSE., To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. DATA SOURCES., Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. CONCLUSIONS AND IMPLICATIONS., Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation. [source] Nursing-Sensitive Outcome Implementation and Reliability Testing in a Tertiary Care SettingINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003Julia G. Behrenbeck PURPOSE To describe the NOC outcomes most relevant for specialty nursing practice and in selected field sites representing the continuum of care; to assess the adequacy of measures (reliability, validity, sensitivity, specificity, practicality); and to describe the linkages among nursing diagnoses, interventions, and outcomes in clinical decision making. METHODS Data were collected on 434 patients during the 12-month data collection period at a tertiary care center: cardiac surgery intensive care (n= 76), cardiac transplant unit (n= 153), and medical unit (n= 205). Medical diagnoses of patients on the two cardiac units were related to cardiac disease. Medical diagnoses of patients on the medical unit were extremely varied (ranging from e.g., gout to pneumonia). Data were collected on 65 separate outcome labels for a total of 633 ratings. FINDINGS In the cardiac transplant ICU, data were collected on 42 outcomes: 30 had an average interrater reliability of ,85%, and 16 had an absolute agreement interrater reliability of ,85%. In the cardiac surgery ICU, data were collected on 30 outcomes: 25 had an average interrater reliabilty of ,85%, 6 had an absolute agreement interrater of ,85%. In the medical unit, data were collected on 45 outcomes: 41 had an average interrater reliability of ,85%, 14 had an absolute agreement interrater reliability of ,85%. Four outcomes have been implemented into the documentation system for all patients: Tissue Integrity: Skin and Mucous Membranes, Mobility Level, Knowledge: Disease Process, and Coping. CONCLUSIONS Overall, nursing staff were very positive about having the opportunity to participate in nursing research. Staff were able to think about the relative status of their patient and how nursing care contributes to the patient's recovery. They appreciated the opportunity to discuss this with a colleague during the interrater exercise. Increased familiarity with NOC allows staff members to determine which outcomes comprise core nursing-sensitive outcomes for their clinical setting. [source] Nursing-Sensitive Outcome Reliability Testing in a Tertiary Care SettingINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 1 2005Julia G. Behrenbeck MS purpose., To describe nursing outcomes classification (NOC) that are most relevant for, specialty acute care nursing practice, and to assess the adequacy of measures. methods., Data were collected on 434 patients during the 14-month data collection period at a tertiary care center: cardiac surgery intensive care (n = 76), cardiac transplant unit (n = 153), and medical unit (n = 205). findings., Thirty-six NOC outcomes were used 10 or more times during the study. Of those, 16 had an inter-rater reliability of 75% or higher. conclusions., NOC outcomes show promise for accurately documenting the effectiveness of nursing interventions. Further study is needed to develop meaningful analysis of the documented NOC outcomes and efficiently integrate NOC into electronic documentation systems. practice implications., Increased familiarity with NOC allowed nursing staff to determine which outcomes comprise core nursing-sensitive outcomes for their clinical setting. [source] Using NIC to Describe the Role of the Nurse PractitionerINTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATION, Issue 2003Cindy S. Haugsdal PURPOSE To have nurse practitioners (NPs) identify the 20 most prevalent NIC interventions describing their nursing practice; to determine if the NIC is applicable to the NP role. METHODS The study used a descriptive survey design. NPs with prescriptive privileges in the state of Minnesota received a cover letter and survey that included a description of NIC and a list of the 486 intervention labels and their definitions from the NIC (3rd ed.). Each participant was asked to identify all interventions performed at least once per month in their practice and to provide basic demographic data, including identification of NP specialty. FINDINGS A total of 1,190 surveys were mailed with a return rate of 37%. NPs' average age was 45 years; the average number of years of NP practice was 9. Employment in a clinic represented the work setting of 72% of respondents followed by hospital practice (11%) and long-term care (10%). Specialty (certified) areas were family practice (27%), pediatrics (21%), adult (19%), women's health (16%), geriatrics (11%), psychiatric (5%), and oncology (1%). The educational level was primarily master's degree (73%). NPs identified an average of 120 interventions they performed at least once per month. These interventions reflected areas of patient education and support, as well as documentation and physician collaboration. The 20 most frequently selected interventions were reported by 71%, 90% of respondents. Four core interventions ,"documentation,""telephone consultation,""teaching: prescribed medication," and "emotional support", were used at least once per month by all specialties. DISCUSSION The level of consistency (70%) among responses validates the strong foundation that professional nursing, as described by NIC, provides NPs in their role. Four core interventions and the remaining 16 most frequently selected interventions that are more specific to each specialty practice indicates that NIC is comprehensive enough to meet the needs of a variety of NP practices. CONCLUSIONS NIC encompasses key areas of interventions (health screening, treatment and management, health promotion and education, psychosocial support, indirect activities) central to the role of NPs, but qualitative comments described the need for more language within NIC to characterize the NP role related to the prescribing of medications and treatments. Some respondents found the definitions to be unclear as to whether they were performing or ordering/prescribing the intervention. This lack of clarity could be addressed by further development of the NIC definitions and activities so the advanced role of the NP is more fully described. Development of documentation systems using the core interventions identified by the various NP specialties is needed. Using standardized nursing language for documentation will enable NPs to build clinical databases that reflect and describe the role. Future research needs to be focused by NP specialty and to go beyond the NIC definition and include analysis at the activity level. [source] SPLASH: Systematic proteomics laboratory analysis and storage hubPROTEINS: STRUCTURE, FUNCTION AND BIOINFORMATICS, Issue 6 2006Siaw Ling Lo Abstract In the field of proteomics, the increasing difficulty to unify the data format, due to the different platforms/instrumentation and laboratory documentation systems, greatly hinders experimental data verification, exchange, and comparison. Therefore, it is essential to establish standard formats for every necessary aspect of proteomics data. One of the recently published data models is the proteomics experiment data repository [Taylor, C. F., Paton, N. W., Garwood, K. L., Kirby, P. D. et,al., Nat. Biotechnol. 2003, 21, 247,254]. Compliant with this format, we developed the systematic proteomics laboratory analysis and storage hub (SPLASH) database system as an informatics infrastructure to support proteomics studies. It consists of three modules and provides proteomics researchers a common platform to store, manage, search, analyze, and exchange their data. (i),Data maintenance includes experimental data entry and update, uploading of experimental results in batch mode, and data exchange in the original PEDRo format. (ii),The data search module provides several means to search the database, to view either the protein information or the differential expression display by clicking on a gel image. (iii),The data mining module contains tools that perform biochemical pathway, statistics-associated gene ontology, and other comparative analyses for all the sample sets to interpret its biological meaning. These features make SPLASH a practical and powerful tool for the proteomics community. [source] | ||||||||||