Rachel Y Lee, Christopher Knaplund, Jennifer Withall, Syed Mohtashim Bokhari, Kenrick D Cato, Sarah C Rossetti
{"title":"病人住院期间护理记录模式的差异。","authors":"Rachel Y Lee, Christopher Knaplund, Jennifer Withall, Syed Mohtashim Bokhari, Kenrick D Cato, Sarah C Rossetti","doi":"","DOIUrl":null,"url":null,"abstract":"<p><p>This study explores the variability in nursing documentation patterns in acute care and ICU settings, focusing on vital signs and note documentation, and examines how these patterns vary across patients' hospital stays, documentation types, and comorbidities. In both acute care and critical care settings, there was significant variability in nursing documentation patterns across hospital stays, by documentation type, and by patients' comorbidities. The results suggest that nurses adapt their documentation practices in response to their patients' fluctuating needs and conditions, highlighting the need to facilitate more individualized care and tailored documentation practices. The implications of these findings can inform decisions on nursing workload management, clinical decision support tools, and EHR optimizations.</p>","PeriodicalId":72180,"journal":{"name":"AMIA ... Annual Symposium proceedings. AMIA Symposium","volume":"2023 ","pages":"1037-1046"},"PeriodicalIF":0.0000,"publicationDate":"2024-01-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10785899/pdf/","citationCount":"0","resultStr":"{\"title\":\"Variability in Nursing Documentation Patterns across Patients' Hospital Stays.\",\"authors\":\"Rachel Y Lee, Christopher Knaplund, Jennifer Withall, Syed Mohtashim Bokhari, Kenrick D Cato, Sarah C Rossetti\",\"doi\":\"\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><p>This study explores the variability in nursing documentation patterns in acute care and ICU settings, focusing on vital signs and note documentation, and examines how these patterns vary across patients' hospital stays, documentation types, and comorbidities. In both acute care and critical care settings, there was significant variability in nursing documentation patterns across hospital stays, by documentation type, and by patients' comorbidities. The results suggest that nurses adapt their documentation practices in response to their patients' fluctuating needs and conditions, highlighting the need to facilitate more individualized care and tailored documentation practices. The implications of these findings can inform decisions on nursing workload management, clinical decision support tools, and EHR optimizations.</p>\",\"PeriodicalId\":72180,\"journal\":{\"name\":\"AMIA ... Annual Symposium proceedings. AMIA Symposium\",\"volume\":\"2023 \",\"pages\":\"1037-1046\"},\"PeriodicalIF\":0.0000,\"publicationDate\":\"2024-01-11\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10785899/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"AMIA ... Annual Symposium proceedings. AMIA Symposium\",\"FirstCategoryId\":\"1085\",\"ListUrlMain\":\"\",\"RegionNum\":0,\"RegionCategory\":null,\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2023/1/1 0:00:00\",\"PubModel\":\"eCollection\",\"JCR\":\"\",\"JCRName\":\"\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"AMIA ... Annual Symposium proceedings. AMIA Symposium","FirstCategoryId":"1085","ListUrlMain":"","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2023/1/1 0:00:00","PubModel":"eCollection","JCR":"","JCRName":"","Score":null,"Total":0}
Variability in Nursing Documentation Patterns across Patients' Hospital Stays.
This study explores the variability in nursing documentation patterns in acute care and ICU settings, focusing on vital signs and note documentation, and examines how these patterns vary across patients' hospital stays, documentation types, and comorbidities. In both acute care and critical care settings, there was significant variability in nursing documentation patterns across hospital stays, by documentation type, and by patients' comorbidities. The results suggest that nurses adapt their documentation practices in response to their patients' fluctuating needs and conditions, highlighting the need to facilitate more individualized care and tailored documentation practices. The implications of these findings can inform decisions on nursing workload management, clinical decision support tools, and EHR optimizations.