Abstract [from journal]
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.