Accepted Manuscript Title: The quality of paper-based versus electronic nursing care plan in Australian aged care homes: a documentation audit study Author: Ning Wang Ping Yu David Hailey PII: DOI: Reference:
S1386-5056(15)00091-X http://dx.doi.org/doi:10.1016/j.ijmedinf.2015.04.004 IJB 3187
To appear in:
International Journal of Medical Informatics
Received date: Revised date: Accepted date:
27-12-2014 26-4-2015 29-4-2015
Please cite this article as: N. Wang, P. Yu, D. Hailey, The quality of paperbased versus electronic nursing care plan in Australian aged care homes: a documentation audit study, International Journal of Medical Informatics (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page Title of the manuscript: The quality of paper-based versus electronic nursing care plan in
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Australian aged care homes: a documentation audit study
1) Ning Wang1, RN, PhD, MPH
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2) Ping Yu1, PhD, Assoc prof - corresponding author
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Authorship of the manuscript:
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3) David Hailey1, PhD
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Affiliation: 1School of Information Systems and Technology, University of Wollongong
d
Author details
Ac ce p
Affiliation:
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Ning Wang, RN, MPH, PhD.
School of Information System and Technology (SISAT) University of Wollongong
Postal address: 35/9-11 Barnsbury Rd South Yarra VIC 3141 Australia Email: [email protected] Tel: +61 3 9994 4068 Mobil +61 425237276
1 Page 1 of 31
Ping Yu - Corresponding author
School of Information Systems and Technology (SISAT)
us
University of Wollongong, Wollongong NSW 2522 Australia
cr
ip t
PhD, Assoc prof
an
Tel: +61 2 4221 5412, Fax: +61 2 4221 4045,
te
d
Website: http://www.uow.edu.au/~ping/
M
Email: [email protected]
Ac ce p
David Hailey, PhD, Professorial Fellow Affiliation:
School of Information Systems and Technology (SISAT) University of Wollongong, Wollongong NSW 2522 Australia Email: [email protected] Keywords: data quality, documentation, nursing care plan, standardized nursing terminology, electronic nursing documentation system, paper-based nursing documentation system.
2 Page 2 of 31
Abstract Introduction: The nursing care plan plays an essential role in supporting care provision in
ip t
Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to
cr
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
us
system on documentation quality in residential aged care need to be investigated.
an
Purpose: 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
M
electronic nursing care plans.
d
Methods: A nursing documentation audit was conducted in seven residential aged care homes in
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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
Ac ce p
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.
Results: 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, p
S1386-5056(15)00091-X http://dx.doi.org/doi:10.1016/j.ijmedinf.2015.04.004 IJB 3187
To appear in:
International Journal of Medical Informatics
Received date: Revised date: Accepted date:
27-12-2014 26-4-2015 29-4-2015
Please cite this article as: N. Wang, P. Yu, D. Hailey, The quality of paperbased versus electronic nursing care plan in Australian aged care homes: a documentation audit study, International Journal of Medical Informatics (2015), http://dx.doi.org/10.1016/j.ijmedinf.2015.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page Title of the manuscript: The quality of paper-based versus electronic nursing care plan in
ip t
Australian aged care homes: a documentation audit study
1) Ning Wang1, RN, PhD, MPH
us
2) Ping Yu1, PhD, Assoc prof - corresponding author
cr
Authorship of the manuscript:
an
3) David Hailey1, PhD
M
Affiliation: 1School of Information Systems and Technology, University of Wollongong
d
Author details
Ac ce p
Affiliation:
te
Ning Wang, RN, MPH, PhD.
School of Information System and Technology (SISAT) University of Wollongong
Postal address: 35/9-11 Barnsbury Rd South Yarra VIC 3141 Australia Email: [email protected] Tel: +61 3 9994 4068 Mobil +61 425237276
1 Page 1 of 31
Ping Yu - Corresponding author
School of Information Systems and Technology (SISAT)
us
University of Wollongong, Wollongong NSW 2522 Australia
cr
ip t
PhD, Assoc prof
an
Tel: +61 2 4221 5412, Fax: +61 2 4221 4045,
te
d
Website: http://www.uow.edu.au/~ping/
M
Email: [email protected]
Ac ce p
David Hailey, PhD, Professorial Fellow Affiliation:
School of Information Systems and Technology (SISAT) University of Wollongong, Wollongong NSW 2522 Australia Email: [email protected] Keywords: data quality, documentation, nursing care plan, standardized nursing terminology, electronic nursing documentation system, paper-based nursing documentation system.
2 Page 2 of 31
Abstract Introduction: The nursing care plan plays an essential role in supporting care provision in
ip t
Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to
cr
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
us
system on documentation quality in residential aged care need to be investigated.
an
Purpose: 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
M
electronic nursing care plans.
d
Methods: A nursing documentation audit was conducted in seven residential aged care homes in
te
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
Ac ce p
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.
Results: 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, p
