What patients’ problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

BackgroundThe nurses’ ability to document patient's status, problems and progress is an important issue in patients’ safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians.ObjectivesThis study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts.DesignObservational, longitudinal, multicentre study.SettingA total of 8 hospitals representing 162 acute medical–surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included.ParticipantsOverall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%).MethodsThe main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals.ResultsMost of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients’ problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25–51.65) or Acute pain (49.6%; CI: 49.49–49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking.ConclusionsResults for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting.