An Essential Clinical Dataset Intervention for Nursing Documentation of a Pediatric Admission History Database.

Autor: Horn JJ; Old Dominion University, Norfolk, VA, United States of America; Children's Mercy - Kansas City, Kansas City, MO, United States of America. Electronic address: jjhorn3@cmh.edu., Doucette JN; Old Dominion University, Norfolk, VA, United States of America; Thomas Jefferson University Hospitals, Philadelphia, PA, United States of America., Sweeney NL; Old Dominion University, Norfolk, VA, United States of America.
Jazyk: angličtina
Zdroj: Journal of pediatric nursing [J Pediatr Nurs] 2021 Jul-Aug; Vol. 59, pp. 110-114. Date of Electronic Publication: 2021 Apr 09.
DOI: 10.1016/j.pedn.2021.03.022
Abstrakt: Purpose: The purpose of this study was to improve nursing documentation efficiencies and satisfaction of a pediatric admission history workflow. Secondary aims determined if defining essential data elements was associated with decreased pediatric admission history documentation time, increased dataset completion rate, and increased satisfaction.
Design and Methods: A quasi-experimental between-group difference comparison was conducted for a nurse-led quality improvement study that included implementation of a pediatric essential clinical dataset (ECD) tool for pre/post-intervention analysis of nursing admission history documentation time, dataset completion rate, and satisfaction. A survey was administered to nurses pre- and post-intervention to compare documentation satisfaction.
Results: Nursing admission history documentation time decreased by 1 min 31 s and the number of clicks decreased 38%. Dataset utilization increased 8% indicating improved nursing documentation of essential questions within a pediatric admission history form. Nursing documentation satisfaction with the pediatric admission history form was minimally impacted by the pediatric ECD study intervention.
Conclusions: Defining what is essential for nurses to document positively influenced nursing documentation time, dataset completion rate, and satisfaction.
Practice Implications: The study contributed to EHR content standardization, optimization, and documentation efficiencies for nurses within a pediatric organization with implications for clinical and informatics collaboration to create real-world evidence, leveraging an intervention that decreased documentation burden and increased time for children and families.
Competing Interests: Declaration of Competing Interest There is no potential conflicts of interest known to any of the contributing authors.
(Copyright © 2021 Elsevier Inc. All rights reserved.)
Databáze: MEDLINE
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