Abstract
Objectives
Illustrate patterns of patient problem information received and documented across
the home health care (HHC) admission process and offer practice, policy, and health
information technology recommendations to improve information transfer.
Design
Observational field study.
Setting and Participants
Three diverse HHC agencies using different commercial point-of-care electronic health
records (EHRs). Six nurses per agency each admitted 2 patients (36 total).
Methods
Researchers observed the admission process and photographed documents and EHR screens
across 3 phases: referral, assessment, and plan of care (POC). To create a standardized
data set, we mapped terms within medical diagnoses, signs, symptoms, and Problems
to 5 of the 42 Omaha System Problem Classification Scheme problem terms. This created
180 problem pattern cases (5 problem patterns per patient).
Results
Each pattern of problem information being present or absent was observed. In 52 cases
(28.9%), a problem did not appear. In 36 cases (20%), the problem appeared in all
3 phases. In 46 cases (25.6%), the problem appeared in referral and/or assessment
phases and not on the POC. Conversely, in 37 cases (20.5%), the problem appeared in
referral or assessment phases and on the POC. In 9 cases (5%), the problem only appeared
on the POC. Within the EHRs, there were no rationale fields to clarify including Problems
or not and no problem status fields to identify active, resolved, or potential ones.
Conclusions and Implications
Diagnosis or problem information transferred from the referral source or gathered
during an in-home assessment did not appear in the POC. Because of the EHR structure,
clinicians could not identify inactive problem or problem priority. Documentation
or mapping of a structured problem list using a standardized interprofessional terminology
such as the Omaha System coupled with identification of rationale could support the
documentation of problem status and priority and reduce information loss.
Keywords
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Article info
Publication history
Published online: July 28, 2020
Footnotes
Funding: This work was supported by the Agency for HealthCare Research and Quality (Grant R01 HS024537) “Information Needs of Homecare Nurses During Admission and Care Planning.” The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
The authors declare no conflicts of interest.
Identification
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© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
