Electronic care documentation should meet the needs of nursing home staff caring for people with dementia
Guidance
EPRElectronic Patient Record An electronic set of information about a single patient systems should include the necessary assessment templates for use in the care of people with dementia, as well as space for entry of free text and to upload photos of residents. Electronic assessment forms and care plans for dementia care should use formalised nursing language to prompt the entry of correct information, and structured templates that guide staff through body systems, leading to comprehensive care plans.
Explanation and Examples
EPRElectronic Patient Record An electronic set of information about a single patient systems in nursing homes have been found to omit the appropriate scales and assessments required by nursing staff caring for people with dementia. For instance, staff stated that they require the MMSEMini Mental State Examination A type of assessment used by clinicians to assist in the diagnosis of dementia, and to establish severity. assessment, the QUALID scaleQuality of life in late-stage dementia scale An observational scale used by clinicians and caregivers to rate quality of life in persons with late-stage dementia., and the Barthel IndexBarthel Index of Activities of Daily Living. A measure of independence in activities of daily living. of Activities of Daily Living incorporated into the EPRElectronic Patient Record An electronic set of information about a single patient. Furthermore, staff have identified incorrect nursing language in electronic forms, meaning important information is not recorded. For example, the omission of the term ‘dementia diagnosis’ from assessment forms meant that nurses were not entering this information about residents. By including the appropriate structured forms for data entry with formalised nursing language, Artificial IntelligenceThe use of computer technology to make computers and other machines think and do things in the way that people can. (Abbreviated to AI) (AIArtificial Intelligence The use of computer technology to make computers and other machines think and do things in the way that people can.) tools can be more successfully integrated into the EPRElectronic Patient Record An electronic set of information about a single patient. Space for photos of residents is important for new staff when learning residents names and for confirming identities of residents when required, and structured body templates included into the EPRElectronic Patient Record An electronic set of information about a single patient have been identified as a useful visual prompt for completing assessments. Staff also require space to enter life stories, and space for free data entry for additional notes and observations. For example, changes in the behaviour of a resident with dementia.
Themes
Assessment Care plans Electronic Patient Record (EPR) Nursing home Nursing language Templates
Target groups
Electronic Patient Records (EPR) developers Nursing homesType of evidence
Integrative literature review
Qualitative study
References
Shiells, K., Holmerova, I., Steffl, M., Stepankova, O. (2018). Electronic patient records as a tool to facilitate care provision in nursing homes: an integrative review. Informatics for Health and Social Care, 44(3), 262-277. doi.org/10.1080/17538157.2018.1496091
‘More of a hindrance than a help’? Staff perspectives on the usability of Electronic Patient Records for planning and delivering dementia care in nursing homes (in draft)