| Abstracting pain management documentation from the electronic medical record: comparison of three hospitals. | |
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MedLine Citation:
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PMID: 20974098 Owner: NLM Status: In-Data-Review |
Abstract/OtherAbstract:
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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. |
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Authors:
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Joanne G Samuels |
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Publication Detail:
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Type: Journal Article Date: 2010-06-29 |
Journal Detail:
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Title: Applied nursing research : ANR Volume: 25 ISSN: 1532-8201 ISO Abbreviation: Appl Nurs Res Publication Date: 2012 May |
Date Detail:
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Created Date: 2012-04-30 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 8901557 Medline TA: Appl Nurs Res Country: United States |
Other Details:
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Languages: eng Pagination: 89-94 Citation Subset: IM; N |
Copyright Information:
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Copyright © 2012 Elsevier Inc. All rights reserved. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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