Distributed Electronic Documentation Practices of Homecare Admission: Informing Electronic Health Record Design Guidelines

摘要

Home care nurses complete many activities as part of the admission process. A pilot study of the home care admission process indicated that a nurse distributes data entry tasks between the patient’s home and a postdocumentation period later in the day. We found evidence of a strategy to document information that requires direct observation (either from the patient or through viewing the home environment) in the home. We found evidence of a strategy to document outside of the home for data elements based on clinical judgment or assessments as well as information supported by clinical decision support in the Electronic Health Record (EHR). These finding inform recommendations for data entry and navigation design guidelines for home care admission EHR systems.