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Adopting an American framework to optimize nursing admission documentation in an Australian health organization

OBJECTIVE: Apply and modify the American Essential Clinical Dataset (ECD) approach to optimize the data elements of an electronic nursing admission assessment form in a metropolitan Australian local health district. MATERIALS AND METHODS: We used the American ECD approach but made modifications. Our...

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Autores principales: Shala, Danielle Ritz, Jones, Aaron, Fairbrother, Greg, Davis, Jordanna, MacGregor, Alastair, Baysari, Melissa
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9272497/
https://www.ncbi.nlm.nih.gov/pubmed/35821796
http://dx.doi.org/10.1093/jamiaopen/ooac054
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author Shala, Danielle Ritz
Jones, Aaron
Fairbrother, Greg
Davis, Jordanna
MacGregor, Alastair
Baysari, Melissa
author_facet Shala, Danielle Ritz
Jones, Aaron
Fairbrother, Greg
Davis, Jordanna
MacGregor, Alastair
Baysari, Melissa
author_sort Shala, Danielle Ritz
collection PubMed
description OBJECTIVE: Apply and modify the American Essential Clinical Dataset (ECD) approach to optimize the data elements of an electronic nursing admission assessment form in a metropolitan Australian local health district. MATERIALS AND METHODS: We used the American ECD approach but made modifications. Our approach included (1) a review of data, (2) a review of current admission practice via consultations with nurses, (3) a review of evidence and policies, (4) workshops with nursing and informatics teams in partnership with the electronic medical record (eMR) vendor, and (5) team debrief sessions to consolidate findings and decide what data elements should be kept, moved, or removed from the admission form. RESULTS: Of 165 data elements in the form, 32% (n = 53) had 0% usage, while 25% (n = 43) had 100% usage. Nurses’ perceptions of the form’s purpose varied. Eight policy documents specifically prescribed data to be noted at admission. Workshops revealed risks of moving or removing data elements, but also uncovered ways of streamlining the form. Consolidation of findings from all phases resulted in a recommendation to reduce 91% of data elements. DISCUSSION: Application of a modified ECD approach allowed the team to identify opportunities for significantly reducing and reorganizing data elements in the eMR to enhance the utility, quality, visibility, and value of nursing admission data. CONCLUSION: We found the modified ECD approach effective for identifying data elements and work processes that were unnecessary and duplicated. Our findings and methodology can inform improvements in nursing clinical practice, information management, and governance in a digital health age.
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spelling pubmed-92724972022-07-11 Adopting an American framework to optimize nursing admission documentation in an Australian health organization Shala, Danielle Ritz Jones, Aaron Fairbrother, Greg Davis, Jordanna MacGregor, Alastair Baysari, Melissa JAMIA Open Research and Applications OBJECTIVE: Apply and modify the American Essential Clinical Dataset (ECD) approach to optimize the data elements of an electronic nursing admission assessment form in a metropolitan Australian local health district. MATERIALS AND METHODS: We used the American ECD approach but made modifications. Our approach included (1) a review of data, (2) a review of current admission practice via consultations with nurses, (3) a review of evidence and policies, (4) workshops with nursing and informatics teams in partnership with the electronic medical record (eMR) vendor, and (5) team debrief sessions to consolidate findings and decide what data elements should be kept, moved, or removed from the admission form. RESULTS: Of 165 data elements in the form, 32% (n = 53) had 0% usage, while 25% (n = 43) had 100% usage. Nurses’ perceptions of the form’s purpose varied. Eight policy documents specifically prescribed data to be noted at admission. Workshops revealed risks of moving or removing data elements, but also uncovered ways of streamlining the form. Consolidation of findings from all phases resulted in a recommendation to reduce 91% of data elements. DISCUSSION: Application of a modified ECD approach allowed the team to identify opportunities for significantly reducing and reorganizing data elements in the eMR to enhance the utility, quality, visibility, and value of nursing admission data. CONCLUSION: We found the modified ECD approach effective for identifying data elements and work processes that were unnecessary and duplicated. Our findings and methodology can inform improvements in nursing clinical practice, information management, and governance in a digital health age. Oxford University Press 2022-07-11 /pmc/articles/PMC9272497/ /pubmed/35821796 http://dx.doi.org/10.1093/jamiaopen/ooac054 Text en © The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. https://creativecommons.org/licenses/by/4.0/This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Research and Applications
Shala, Danielle Ritz
Jones, Aaron
Fairbrother, Greg
Davis, Jordanna
MacGregor, Alastair
Baysari, Melissa
Adopting an American framework to optimize nursing admission documentation in an Australian health organization
title Adopting an American framework to optimize nursing admission documentation in an Australian health organization
title_full Adopting an American framework to optimize nursing admission documentation in an Australian health organization
title_fullStr Adopting an American framework to optimize nursing admission documentation in an Australian health organization
title_full_unstemmed Adopting an American framework to optimize nursing admission documentation in an Australian health organization
title_short Adopting an American framework to optimize nursing admission documentation in an Australian health organization
title_sort adopting an american framework to optimize nursing admission documentation in an australian health organization
topic Research and Applications
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9272497/
https://www.ncbi.nlm.nih.gov/pubmed/35821796
http://dx.doi.org/10.1093/jamiaopen/ooac054
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