Document Detail


Abstracting pain management documentation from the electronic medical record: comparison of three hospitals.
MedLine Citation:
PMID:  20974098     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
BACKGROUND: Pain management science results are derived from research conducted using medical record.
APPROACH: This article describes methodological issues arising from abstracting pain management documentation (PMD) from the electronic medical record in three hospitals. After approval, PMD data were collected from the patient's history and physical, discharge summary, operative care notes, computerized nursing flow sheets, progress notes, and medication records.
RESULTS: Each acute care facility required a different approach to abstract data. Inconsistent documentation in pain management assessments, interventions, and reassessments were identified across hospitals.
DISCUSSION: Inconsistencies pose measurement threats and hinder benchmarking efforts. Work to standardize PMD across propriety computer systems is warranted.
Authors:
Joanne G Samuels
Related Documents :
20180438 - The veterans affairs shift change physician-to-physician handoff project.
20811768 - Design and development of emr supporting medical process management.
7560958 - Advances in rapid laboratory diagnosis of infectious endophthalmitis.
10724888 - Third generation electronic pharmacy communications. recommendations based on ten years...
20180438 - The veterans affairs shift change physician-to-physician handoff project.
11412888 - What defines a view?
Publication Detail:
Type:  Journal Article     Date:  2010-06-29
Journal Detail:
Title:  Applied nursing research : ANR     Volume:  25     ISSN:  1532-8201     ISO Abbreviation:  Appl Nurs Res     Publication Date:  2012 May 
Date Detail:
Created Date:  2012-04-30     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  8901557     Medline TA:  Appl Nurs Res     Country:  United States    
Other Details:
Languages:  eng     Pagination:  89-94     Citation Subset:  IM; N    
Copyright Information:
Copyright © 2012 Elsevier Inc. All rights reserved.
Export Citation:
APA/MLA Format     Download EndNote     Download BibTex
MeSH Terms
Descriptor/Qualifier:

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


Previous Document:  Evaluation of the Tiredness Management Guide: a pilot study.
Next Document:  Validity of the Braden and Waterlow subscales in predicting pressure ulcer risk in hospitalized pati...