Completion of electronic nursing documentation of inpatient admission assessment: Insights from Australian metropolitan hospitals. 2021

Danielle Ritz Shala, and Aaron Jones, and Greg Fairbrother, and Duong Thuy Tran
Nursing and Midwifery Services, Sydney Local Health District, Camperdown, NSW, Australia; Health Informatics Unit, Sydney Local Health District, Camperdown, NSW, Australia; Centre for Big Data Research in Health, University of New South Wales, Kensington, NSW, Australia. Electronic address: d.shala@unswalumni.com.

Electronic nursing documentation is an essential aspect of inpatient care and multidisciplinary communication. Analysing data in electronic medical record (eMR) systems can assist in understanding clinical workflows, improving care quality, and promoting efficiency in the healthcare system. This study aims to assess timeliness of completion of an electronic nursing admission assessment form and identify patient and facility factors associated with form completion in three metropolitan hospitals. Records of 37,512 adult inpatient admissions (November 2018-November 2019) were extracted from the hospitals' eMR system. A dichotomous variable descriptive of completion of the nursing assessment form (Yes/No) was created. Timeliness of form completion was calculated as the interval between date and time of admission and form completion. Univariate and multivariate multilevel logistic regression were used to identify factors associated with form completion. An admission assessment form was completed for 78.4% (n = 29,421) of inpatient admissions. Of those, 78% (n = 22,953) were completed within the first 24 h of admission, 13.3% (n = 3,910) between 24 and 72 h from admission, and 8.7% (n = 2,558) beyond 72 h from admission. Patient length of hospital stay, admission time, and admitting unit's nursing hours per patient day were associated with form completion. Patient gender, age, and admitting unit type were not associated with form completion. Form completion rate was high, though more emphasis needs to be placed on the importance of timely completion to allow for adequate patient care planning. Staff education, qualitative understanding of delayed form completion, and streamlined guidelines on nursing admission and eMR use are recommended.

UI MeSH Term Description Entries
D007297 Inpatients Persons admitted to health facilities which provide board and room, for the purpose of observation, care, diagnosis or treatment. Inpatient
D010343 Patient Admission The process of accepting patients. The concept includes patients accepted for medical and nursing care in a hospital or other health care institution. Voluntary Admission,Admission, Patient,Admission, Voluntary,Admissions, Patient,Admissions, Voluntary,Patient Admissions,Voluntary Admissions
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D004581 Electronics The study, control, and application of the conduction of ELECTRICITY through gases or vacuum, or through semiconducting or conducting materials. (McGraw-Hill Dictionary of Scientific and Technical Terms, 6th ed) Electronic
D006786 Hospitals, Urban Hospitals located in metropolitan areas. City Hospitals,Hospitals, City,Hospitals, City, Non-Public-Owned,Hospitals, Metropolitan,Urban Hospitals,City Hospitals, Non-Public-Owned,Metropolitan Hospitals,Non-Public-Owned City Hospitals,City Hospital,City Hospital, Non-Public-Owned,City Hospitals, Non Public Owned,Hospital, City,Hospital, Metropolitan,Hospital, Non-Public-Owned City,Hospital, Urban,Hospitals, Non-Public-Owned City,Metropolitan Hospital,Non Public Owned City Hospitals,Non-Public-Owned City Hospital,Urban Hospital
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D001315 Australia The smallest continent and an independent country, comprising six states and two territories. Its capital is Canberra. Canton and Enderbury Islands,Christmas Island,Christmas Island (Australia)
D057286 Electronic Health Records Media that facilitate transportability of pertinent information concerning patient's illness across varied providers and geographic locations. Some versions include direct linkages to online CONSUMER HEALTH INFORMATION that is relevant to the health conditions and treatments related to a specific patient. Electronic Health Record Data,Electronic Medical Record,Electronic Medical Records,Computerized Medical Record,Computerized Medical Records,Electronic Health Record,Medical Record, Computerized,Medical Records, Computerized,Health Record, Electronic,Health Records, Electronic,Medical Record, Electronic,Medical Records, Electronic

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