Drexel University, College of Nursing and Health Professions, Philadelphia, PA.
Department of Biobehavioral Health Science, University of Pennsylvania School of Nursing, Philadelphia, PA; Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, NY.
J Am Med Dir Assoc. 2021 May;22(5):1009-1014. doi: 10.1016/j.jamda.2020.06.032. Epub 2020 Jul 29.
Illustrate patterns of patient problem information received and documented across the home health care (HHC) admission process and offer practice, policy, and health information technology recommendations to improve information transfer.
Observational field study.
Three diverse HHC agencies using different commercial point-of-care electronic health records (EHRs). Six nurses per agency each admitted 2 patients (36 total).
Researchers observed the admission process and photographed documents and EHR screens across 3 phases: referral, assessment, and plan of care (POC). To create a standardized data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created 180 problem pattern cases (5 problem patterns per patient).
Each pattern of problem information being present or absent was observed. In 52 cases (28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all 3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared on the POC. Within the EHRs, there were no rationale fields to clarify including Problems or not and no problem status fields to identify active, resolved, or potential ones.
Diagnosis or problem information transferred from the referral source or gathered during an in-home assessment did not appear in the POC. Because of the EHR structure, clinicians could not identify inactive problem or problem priority. Documentation or mapping of a structured problem list using a standardized interprofessional terminology such as the Omaha System coupled with identification of rationale could support the documentation of problem status and priority and reduce information loss.
说明整个家庭保健（HHC）入院过程中患者问题信息的接收和记录模式，并提供实践、政策和健康信息技术建议，以改善信息传递。
观察性现场研究。
三家使用不同商业即时护理电子病历（EHR）的多元化 HHC 机构。每家机构的 6 名护士各收治 2 名患者（共 36 名患者）。
研究人员观察了入院过程，并在 referral、assessment 和 plan of care（POC）三个阶段拍摄了文件和 EHR 屏幕的照片。为了创建一个标准化数据集，我们将医疗诊断、体征、症状和问题中的术语映射到 Omaha 系统问题分类方案的 5 个问题术语中。这创建了 180 个问题模式案例（每个患者 5 个问题模式）。
观察到存在或不存在的问题信息的每种模式。在 52 个案例（28.9%）中，没有出现问题。在 36 个案例（20%）中，问题出现在所有 3 个阶段。在 46 个案例（25.6%）中，问题出现在 referral 和/或 assessment 阶段，而不在 POC 中。相反，在 37 个案例（20.5%）中，问题出现在 referral 或 assessment 阶段，并在 POC 中。在 9 个案例（5%）中，问题仅出现在 POC 中。在 EHR 中，没有说明包括问题的理由字段，也没有问题状态字段来识别活动、已解决或潜在的问题。
从转介源转移或在家庭评估期间收集的诊断或问题信息未出现在 POC 中。由于 EHR 结构，临床医生无法识别非活动问题或问题优先级。使用 Omaha 系统等标准化的跨专业术语对结构化问题清单进行文档记录或映射，并结合理由识别，可以支持问题状态和优先级的文档记录，并减少信息丢失。
