Keywords

Documentation, Electronic health record, Meaningful use, Nursing informatics, Rural hospital, SQL, Structured Query Language

 

Authors

  1. MOERBE, MIRIAM MS, RN
  2. KELEMEN, ARPAD PhD

Abstract

The combination of nursing informatics knowledge with SQL code writing in an electronic health record is a powerful partnership to obtain meaningful information and improve healthcare. The purpose of this project is to use SQL and nursing informatics to identify the underpinnings and scope of present-on-patient-admission pressure ulcer documentation incongruence within the inpatient medical-surgical unit of a rural hospital. Project results reveal a 76% incidence rate of incongruent nurse and physician documentation of pressure ulcers as present on admission. However, the scope of such incongruence affects only 3% for the inpatient population. The high incidence rate of nurse-documented present-on-admission pressure ulcers without a physician diagnoses indicates a potential for lost rural hospital reimbursement and risk to patient care.