Describing Pediatric Hospital Discharge Planning Care Processes Using the Omaha System

Purpose Although discharge planning (DP) is recognized as a critical component of hospital care, national initiatives have focused on older adults, with limited focus on pediatric patients. We aimed to describe patient problems and targeted interventions as documented by social workers or DP nurses providing specialized DP services in a children\u27s hospital. Methods Text from 67 clinical notes for 28 patients was mapped to a standardized terminology (Omaha System). Data were deductively analyzed. Results A total of 517 phrases were mapped. Eleven of the 42 Omaha System problems were identified. The most frequent problem was health care supervision (297/517; 57.4%). Three Omaha System intervention categories were used (teaching, guidance, and counseling; case management; and surveillance). Intervention targets are varied by role. Conclusion The findings provide a rich description of the nature of DP for complex pediatric patients and increase our understanding of the work of DP staff and the influence of the DP practice model

Investigation Interoperability Problems in Pharmacy Automation: A Case Study in Saudi Arabia

The aim of this case study is to investigate the nature of interoperability problems in hospital systems automation. One of the advanced healthcare providers in Saudi Arabia is the host of the study. The interaction between the pharmacy system and automated medication dispensing cabinets is the focus of the case system. The research method is a detailed case study where multiple data collection methods are used. The modelling of the processes of inpatient pharmacy systems is presented using Business Process Model Notation. The data collected is analysed to study the different interoperability problems. This paper presents a framework that classifies health informatics interoperability implementation problems into technical, semantic, organisational levels. The detailed study of the interoperability problems in this case illustrates the challenges to the adoption of health information system automation which could help other healthcare organisations in their system automation projects

Formal nursing terminology systems: a means to an end

In response to the need to support diverse and complex information requirements, nursing has developed a number of different terminology systems. The two main kinds of systems that have emerged are enumerative systems and combinatorial systems, although some systems have characteristics of both approaches. Differences in the structure and content of terminology systems, while useful at a local level, prevent effective wider communication, information sharing, integration of record systems, and comparison of nursing elements of healthcare information at a more global level. Formal nursing terminology systems present an alternative approach. This paper describes a number of recent initiatives and explains how these emerging approaches may help to augment existing nursing terminology systems and overcome their limitations through mediation. The development of formal nursing terminology systems is not an end in itself and there remains a great deal of work to be done before success can be claimed. This paper presents an overview of the key issues outstanding and provides recommendations for a way forward

PERANCANGAN APLIKASI ELECTRONIC MEDICAL RECORD (EMR) PADA INSTALASI RAWAT INAP BERBASIS WEB

Pelayanan medik dewasa ini membutuhkan sistem yang lebih efektif dan efisien, baik dalam penggunaan waktu, tenaga maupun sarana. Dalam pengelolaan rekam medik, kenyataan masih umumnya penggunaan rekam medik manual yang dinilai tak lagi andal menangani data medik melahirkan ide konversi rekam medik manual kertas ke rekam medik elektronik karena efektivitas dan efisiensinya. Penelitian ini bertujuan menciptakan aplikasi rekam medik elektronik yang lebih dikenal sebagai EMR (Electronic Medical Record) dari rekam medik kertas di Instalasi Rawat Inap Rumah Sakit Umum Ananda Salatiga. Rekam medik elektronik dirancang dengan membuat form-form isian catatan-catatan medik dalam proses perawatan pasien selama dirawat. Data-data medik ini kemudian disimpan dalam basis data sistem dan dikelola secara digital. Setiap kali pengisian data medik pada form-form tertentu, sistem akan menghasilkan kode yang membawa informasi khusus. Pada akhirnya, sistem akan menghasilkan deret kode ICD (International Statistical Classification of Diseases and Related Health Problems) dari kode-kode yang dihasilkan pada pengisian form-form catatan medik. Deretan kode-kode ini mampu menggambarkan perkembangan kondisi pasien dan penanganan medik yang diberikan selama perawatan. Data-data medik yang tersimpan dapat ditampilkan kembali dalam bentuk catatan medik digital. Kata kunci: rekam medik, rawat inap, EMR, IC

Understanding the use of standardized nursing terminology and classification systems in published research : a case study using the International Classification for Nursing Practice®

Background In the era of evidenced based healthcare, nursing is required to demonstrate that care provided by nurses is associated with optimal patient outcomes, and a high degree of quality and safety. The use of standardized nursing terminologies and classification systems are a way that nursing documentation can be leveraged to generate evidence related to nursing practice. Several widely-reported nursing specific terminologies and classifications systems currently exist including the Clinical Care Classification System, International Classification for Nursing Practice®, Nursing Intervention Classification, Nursing Outcome Classification, Omaha System, Perioperative Nursing Data Set and NANDA International. However, the influence of these systems on demonstrating the value of nursing and the professions’ impact on quality, safety and patient outcomes in published research is relatively unknown. Purpose This paper seeks to understand the use of standardized nursing terminology and classification systems in published research, using the International Classification for Nursing Practice® as a case study. Methods A systematic review of international published empirical studies on, or using, the International Classification for Nursing Practice® were completed using Medline and the Cumulative Index for Nursing and Allied Health Literature. Results Since 2006, 38 studies have been published on the International Classification for Nursing Practice®. The main objectives of the published studies have been to validate the appropriateness of the classification system for particular care areas or populations, further develop the classification system, or utilize it to support the generation of new nursing knowledge. To date, most studies have focused on the classification system itself, and a lesser number of studies have used the system to generate information about the outcomes of nursing practice. Conclusions Based on the published literature that features the International Classification for Nursing Practice, standardized nursing terminology and classification systems appear to be well developed for various populations, settings and to harmonize with other health-related terminology systems. However, the use of the systems to generate new nursing knowledge, and to validate nursing practice is still in its infancy. There is an opportunity now to utilize the well-developed systems in their current state to further what is know about nursing practice, and how best to demonstrate improvements in patient outcomes through nursing care