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Use of paper |
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Most forms (24)
Used graphics for patient progress
Transcription of EHR data to paper (eg, labs, meds, orders)
Moderate use of personalized ‘scraps’ to organize nursing activities
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Balance of paper versus electronic charting |
Primarily used paper documentation |
Maintained both paper and electronic records (site with greatest amount of electronic documentation) |
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RN hand-off practices |
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B1 used audio-taped report on all unit patients
Focused on tasks to be completed
Most consistent hand-off (format and content) among all eight study units
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Individual face-to-face hand-offs at computer stations outside patients' rooms
Shortest hand-offs
Utilized paper Kardex, computer MAR, paper flow sheet, and scraps
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Individual face-to-face hand-off at nursing station
Oncoming RNs viewed paper forms before hand-off
Focus was on completed and future tasks
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Theme 2: absence of a centralized care overview in the patient's EHR |
Patient overview forms homegrown and not part of the patient's record |
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Patient overview on a report sheet
Master copy of overviews on all unit patients at front desk, updated throughout patient stay
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Theme 3: rarity of interdisciplinary communication |
Across sites |
Paper forms designed to facilitate interdisciplinary communication were infrequently used.
Non-nurse disciplines were rarely present on the patient care unit.
Majority of ‘other’ discipline communication took place by phone.
Efficiency of care was dramatically affected when needed care team member was unavailable.
RNs frequently consolidated and interpreted information from a variety of sources and disciplines to coordinate care without seeking team validation.
Information related during interdisciplinary communication was rarely documented.
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