Authors:
Ryoma Seto
1
and
Toshitaka Inoue
2
Affiliations:
1
Tokyo Healthcare University, Japan
;
2
Nishikyushu University and Seishinkai Inoue Hospital, Japan
Keyword(s):
Clinical Documentation Improvement, Electronic Health Records, Nursing Documentation, Patient Safety, Vital Signs Documentation, Post-Acute Care Settings.
Abstract:
Although nursing documentation is very important for patient safety, it forces nurses to spend increasing amounts of their working time completing it. In this study, I evaluated the time lag between patient events to completion of nursing documentation at two Post-Acute Care settings (called as “Care-Mixed Hospital” in Japan, similar to nursing home). The mean time lag at Hospital A, which did not implement an automatic documentation system (ADS) was 197.3 min [progress note regarding vital signs (VS), 208.2 min and the others, 196.1 min. The mean time lag at Hospital B, which had implemented ADS, was 3.2 min (only progress note regarding VS). ADS is effective in improving instantaneity on nursing documentation at post-acute care settings.