Do nurses document all discussions of patient problems and nursing interventions in the electronic health record? A pilot study in home healthcare.

ABSTRACT:

Objective

To assess the overlap of information between electronic health record (EHR) and patient-nurse verbal communication in home healthcare (HHC).

Methods

Patient-nurse verbal communications during home visits were recorded between February 16, 2021 and September 2, 2021 with patients being served in an organization located in the Northeast United States. Twenty-two audio recordings for 15 patients were transcribed. To compare overlap of information, manual annotations of problems and interventions were made on transcriptions as well as information from EHR including structured data and clinical notes corresponding to HHC visits.

Results

About 30% (1534/5118) of utterances (ie, spoken language preceding/following silence or a change of speaker) were identified as

SUBMITTER: Song J 

PROVIDER: S-EPMC9154272 | biostudies-literature | 2022 Jul

REPOSITORIES: biostudies-literature