Computers, informatics, nursing : CIN
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In reaching the goal for standardized, quality care, a not-for-profit healthcare system consisting of seven institutional entities is transforming nursing practice guidelines, patient care workflow, and patient documents into electronic, online, real-time modalities for use across departments and all healthcare delivery entities of the system. Organizational structure and a strategic plan were developed for the 2-year Clinical Transformation Project. The Siemens Patient Care Document System was adopted and adapted to the hospitals' documentation and information needs. ⋯ For example, the bar-coded Medication Administration Check System is in full use on the clinical units of one of the hospitals, and the other institutional entities are at substantial stages of implementation of Patient Care Documentation System. The project requires significant allocation of personnel and financial resources for a highly functional informatics system that will transform clinical care. The project exemplifies four of the Magnet ideals and serves as a model for others who may be deciding about launching a similar endeavor.
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Vital signs are a fundamental component of patient care. Omitted or inaccurately transcribed vital sign data could result in inappropriate, delayed, or missed treatment. A previous baseline study determined that error rates for vital signs captured on plain paper then entered into a paper chart or EMR were 10% and 4.4%, respectively. ⋯ This represented a significant reduction in vital sign documentation errors with the use of mobile technology when compared with traditional charting methods (P < .001). The automated vital sign data upload system helped promote a culture of patient safety by greatly reducing documentation error rates. Additional safety benefits may include improved timeliness to vital sign data and clinical work-flow processes.
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Work sampling measured nurse documentation time before and after the implementation of an electronic medical record on a medical-surgical nursing unit. Documentation was separated into subprocesses of admissions, discharges, and routine/daily documentations. ⋯ Post-electronic medical record documentation time was longer than that in the pre-electronic medical record for patients discharged to a nursing home. It was demonstrated that the electronic medical record may reduce documentation time after the adoption of computerized physician order entry.
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This article describes the development and implementation of a nursing clinical decision support system that prompts nurses to place mechanically ventilated patients in a semirecumbent position in the absence of contraindications. A literature review is provided regarding (1) ventilator-associated pneumonia and recommendations from expert panels to maintain mechanically ventilated patients in a semirecumbent position (unless contraindicated) and (2) clinical decision support systems. ⋯ Despite recommendations from organizations such as the Center for Disease Control and Prevention to maintain mechanically ventilated patients in a head-elevated position, there is evidence that the practice is not adequately adhered to. Therefore, a nursing clinical decision support system (in the form of a reminder) that prompts nurses to adhere to this recommendation was designed and implemented.
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This article provides an overview of the Clinical Care Classification System Version 2.0, a standardized coded nursing terminology designed to enhance nursing visibility. The article provides a background as to why a coded language is needed to describe the "essence of care" to validate patient outcomes. ⋯ Examples of the two terminologies are presented with detailed explanations about the coding process. The article highlights the attributes of the Clinical Care Classification System and its place in electronic health record systems.