Outcome calculations based on nursing documentation in the first generation of electronic health records in the Netherlands

Abstract

Objectives. Previous studies regarding nursing documentation focused primarily on documentation quality, for instance, in terms of the accuracy of the documentation. The combination between accuracy measurements and the quality and frequencies of outcome variables such as the length of the hospital stay were only minimally addressed. Method. An audit of 300 randomly selected digital nursing records of patients (age of >70 years) admitted between 2013-2014 for hip surgery in two orthopaedic wards of a general Dutch hospital was conducted. Results. Nursing diagnoses: Impaired tissue perfusion (wound), Pressure ulcer, and Deficient fluid volume had significant influence on the length of the hospital stay. Conclusion. Nursing process documentation can be used for outcome calculations. Nevertheless, in the first generation of electronic health records, nursing diagnoses were not documented in a standardized manner (First generation 2010-2015; the first generation of electronic records implemented in clinical practice in the Netherlands).