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The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated.To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans.A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study.There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes.The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes.

Ethical and legal requirements for healthcare providers in the United States, stipulate that patients sign a consent form prior to undergoing medical treatment or participating in a research study. Currently, the majority of the hospitals obtain these consents using paper-based forms, which makes patient preference data cumbersome to store, search and retrieve. To address these issues, Health Sciences of South Carolina (HSSC), a collaborative of academic medical institutions and research universities in South Carolina, is developing an electronic consenting system, the Research Permissions Management System (RPMS). This article reports the findings of a study conducted to investigate the efficacy of the two proposed interfaces for this system - an iPad-based and touchscreen-based by comparing them to the paper-based and Topaz-based systems currently in use.This study involved 50 participants: 10 hospital admission staff and 40 patients. The four systems were compared with respect to the time taken to complete the consenting process, the number of errors made by the patients, the workload experienced by the hospital staff and the subjective ratings of both patients and staff on post-test questionnaires.The results from the empirical study indicated no significant differences in the time taken to complete the tasks. More importantly, the participants found the new systems more usable than the conventional methods with the registration staff experiencing the least workload in the iPad and touchscreen-based conditions and the patients experiencing more privacy and control during the consenting process with the proposed electronic systems. In addition, they indicated better comprehension and awareness of what they were signing using the new interfaces.The results indicate the two methods proposed for capturing patient consents are at least as effective as the conventional methods, and superior in several important respects. While more research is needed, these findings suggest the viability of cautious adoption of electronic consenting systems, especially because these new systems appear to address the challenge of identifying the participants required for the complex research being conducted as the result of advances in the biomedical sciences.

Objective Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR. Materials and methods Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR. Results Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after “go-live”. These increases abated at differing rates predicted by participants’ computer attitudes scores (p = 0.01). Conclusions There is substantially increased cognitive workload for nurses during the early phases (1–5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to “meaningful use” EHRs. “One-size-fits-all” training strategies may not be suitable and longer periods of technical support may be necessary for some workers.

Purpose To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment. Methods This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated. Results Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms). Conclusions Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records.Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level.Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p0.01), suggesting more items designed in a form, more information would be captured.Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content.