ARTICLE IN PRESS. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s x x x ( ) xxx xxx

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1 IJB-2938; No. of Pges 12 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx j ourn l homepge: Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities Ning Wng, Ping Yu, Dvid Hiley Helth Informtics Reserch Lortory, School of Informtion Systems nd Technology, Fculty of Informtics, University of Wollongong, Austrli r t i c l e i n f o Article history: Received 29 Septemer 2011 Received in revised form 23 Octoer 2012 Accepted 16 Novemer 2012 Keywords: Admission form Auditing Electronic helth record Electronic record Evlution Nursing documenttion Pper record Qulity s t r c t Purpose: To descrie the pper-sed nd electronic formts of resident dmission forms used in severl ged cre fcilities in Austrli nd to compre the extent to which resident dmission informtion ws documented in pper-sed nd the electronic helth records. Methods: Retrospective uditing nd comprison of the documenttion qulity of ppersed nd electronic resident dmission forms were conducted. A checklist of dmission dt ws qulittively derived from different formts of the dmission forms collected. Three mesures were used to ssess the qulity of documenttion of the dmission forms, including completeness rte, comprehensiveness rte nd frequency of documented dt element. The ssocitions etween the numer of items nd their completeness nd comprehensiveness rtes were estimted t generl level nd t ech informtion ctegory level. Results: Vrious pper-sed nd electronic formts of dmission forms were collected, reflecting vrying prctice mong the prticipnt fcilities. The overll completeness nd comprehensiveness rtes of the dmission forms were poor, ut were higher in the electronic helth records thn in the pper-sed records (60% versus 56% nd 40% versus 29% respectively, p < 0.01). There were differences in the overll completeness nd comprehensiveness rtes etween the different formts of dmission forms (p < 0.01). At ech informtion ctegory level, vrying degrees of difference in the completeness nd comprehensiveness rtes were found etween different form formts nd etween the pper-sed nd the electronic records. A negtive ssocition etween the completeness rte nd the numer of items in form ws found t ech informtion ctegory level (p < 0.01), i.e., more dt items designed in form, the less likely tht the items would e completely filled. However, the ssocitions etween the comprehensiveness rtes nd the numer of items were highly positive t oth overll nd individul informtion ctegory levels (p < 0.01), suggesting more items designed in form, more informtion would e cptured. Corresponding uthor t: Helth Informtics Reserch Lortory, School of Informtion Systems nd Technology, Fculty of Informtics, University of Wollongong, Northfields Ave, Wollongong, NSW 2522, Austrli. Tel.: ; fx: E-mil ddress: ping@uow.edu.u (P. Yu) /$ see front mtter 2012 Elsevier Irelnd Ltd. All rights reserved. Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

2 IJB-2938; No. of Pges 12 2 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx Conclusion: Better qulity of documenttion in resident dmission forms ws identified in the electronic documenttion systems thn in previous pper-sed systems, ut still needs to e further improved in prctice. The qulity of documenttion of resident dmission dt should e further nlysed in reltion to its specific content Elsevier Irelnd Ltd. All rights reserved. 1. Introduction The importnce of informtion out clients nd cre in the opertion of modern helth cre orgnistions hs een well recognised [1 3]. Informtion systems tht fcilitte dt collection nd trcking for ptient cre cn lso sustin cre qulity improvement [4]. In the pst decdes, ppliction of electronic helth records (EHRs) hs stremlined dt processing nd mngement in mny helth cre settings with enefits of incresing ccess to more complete, ccurte nd up-to-dte dt nd reducing redundncy [1,5 7]. In ged cre settings, the implementtion of EHRs hs potentil to improve qulity of cre, efficiency of opertion nd integrtion of services [4]. Given the fundmentl significnce of nursing documenttion in Austrlin ged cre sector for the purposes of funding, ccredittion nd qulity improvement [8 10], severl ged cre orgnistions in Austrli hve implemented EHRs. Cregivers perceived the enefits of the implementtion of the EHRs s the provision of more ccurte, legile nd complete informtion nd reduction of repetition in dt entry [11]. In this pper, we report n udit study to investigte the ctul effect of the EHRs on the qulity of nursing documenttion. As significnt prt of resident records in ged cre, resident dmission forms contin informtion out residents personl nd helth history, support networks nd dischrge plnning. Such resident dt re essentil for dministrtive purposes, resident ssessment, nd cre plnning. Qulity resident dmission dt my lso ply vitl role in service coordintion, pulic helth reserch nd helth plnning. Numerous studies hve een crried out to investigte the impct of EHRs on the informtion qulity of rnge of documenttion components nd improved completeness of documenttion with EHRs hs een reported [12]. However, more omissions nd errors in the EHRs were lso reported [13]. Severl studies conducted in cute settings hve reported poor completeness of selected elements of dmission informtion such s dmission dignosis, llergies, mediction, occuption, socil clss, nme/telephone of contct person nd religion [14 17]. In regrd to EHRs, Prins et l. [16] identified indequte documenttion of dmission dignoses nd reson for dmission. Pringle et l. s study [18] showed tht the documenttion of occuption ws incomplete nd no informtion out socil clss nd ethnicity hd een recorded. In ddition, Floor-Schreudering et l. [19] hve reported poor documenttion in EHRs of ptients telephone numers nd drug history fter their first visit to locl phrmcy. However, indequte reserch ttention hs een pid to the qulity of overll dmission informtion. To dte, there hs een no study on the qulity of dmission dt in the ged cre setting. Therefore, our study investigted the qulity of resident dmission dt documented in pper-sed nd electronic dmission forms in severl ged cre fcilities from different orgnistions where commercil EHRs hd een implemented. The ojectives of the study were to descrie the pper-sed nd electronic formts of resident dmission forms used in the ged cre fcilities; nd to compre the extent to which resident dmission informtion ws documented in these formts. 2. Methods 2.1. Study design This ws nursing documenttion udit study. Retrospective review nd comprison of the documenttion qulity of pper-sed nd electronic resident dmission forms were conducted Setting The study ws crried out t nine residentil ged cre fcilities (RACFs) from three ged cre orgnistions in Austrli (coded s Orgnistion 1, 2 nd 3, respectively). These orgnistions hve implemented two commercil EHR systems t different time points since 2005: Softwre 1 ws implemented in Orgnistion 1 nd Softwre 2 ws implemented in Orgnistions 2 nd Smple The study smples were the resident records conveniently selected from the nine RACFs. These included 251 electronic nd 147 pper-sed resident dmission forms from the resident records. The numer of smples vried mong the nine fcilities due to differences in the numer of residents who gve their consent nd the unvilility of rchived ppersed records t some fcilities Prticipnts Prticipnts were the residents of the RACFs whose dmission forms were ccessed y the reserchers fter consent hd een provided. Before seeking written consent, n informtion sheet with detiled description out the study including dt hndling procedures ws given to the residents or to their representtives, depending on the residents cognitive cpcity Ethics pprovl The study ws pproved y University of Wollongong/Illwrr Are Helth Service Humn Reserch Ethics Committee nd the ethics committee of prticipting ged cre orgnistion. Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

3 IJB-2938; No. of Pges 12 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx Development of n uditing checklist A checklist to compre the documenttion qulity of the different dmission form formts used y the RACFs ws developed using dt elements tht were qulittively derived from the dmission forms using similr pproch to tht of Schleyer et l. [20]. The different formts of forms used y the RACFs shred some common items, ut vried in their content. As the study ws intended to present full picture out the scope of informtion to e collected from the residents y using the dmission forms, the checklist included ll items in the included dmission forms, except those out resident dischrge informtion. Dischrge-relted items were excluded ecuse most of the prticipting residents dmission sttus ws current. Inclusion of ll items from the different dmission forms recognised tht they hd een developed nd vlidted y experienced nursing mngers in ech ged cre orgnistion. Thus the nursing knowledge cptured in the dmission forms ws vlule nd should e respected. During the development of the checklist, ll items from ech formt of the dmission forms were extrcted nd then grouped into ctegories. Under ech ctegory, ny duplicted items were merged to form single dt element for the checklist, including items referring to the sme concept, ut nmed differently (e.g., Admission Dte nd Dte of Entry ). For items designed to collect similr type of dt ut with different levels of grnulrity from generl to specific, summry term ws dopted to form single dt element. For exmple, Medicl/Surgicl Dignosis ws used in the checklist for severl items such s Provisionl Dignosis, Principl Dignosis, Principl Opertion nd Mjor Procedure nd Other Opertions or Procedures. Additionlly, some seprte items tht re relted to ech other were comined to single dt element. For exmple, Surnme nd First Nme were comined to form dt element of Full Nme. The checklist ws used to determine whether or not informtion on individul items hd een entered into individul dmission forms. No ttempt ws mde to determine whether the items were pplicle to individuls s the reserchers did not hve direct contct with the residents. Nor ws the qulity of nrrtive entries for some items considered. The vlidity of the checklist ws sed on how well its contents cptured the detils from ll the resident dmission form formts. The checklist ws judged y three helth informtics reserchers who considered nd reched consensus on the ppropriteness of ctegoristion of the items. The checklist contined 10 ctegories with 105 dt elements. These entirely covered the dt intended to e collected y vrious dmission forms from residents t their dmission. Detiled informtion out the checklist is displyed in Tle 1. A dichotomous scle with yes/no options ws dopted to score ech dmission form depending on the occurrence of documenttion for ech of the dt elements. One point ws given to yes option nd zero ws given to no opinion. Two reserchers greed on the protocol for rting the dmission forms nd then grded the forms in the smple from the RACFs using the checklist spredsheet listing the dt elements. During this process, ny question or disgreement ws discussed to rech consensus Mesurement pproches Quntittive description of documenttion of dmission forms ws mde through mpping items completed in n dmission form to the items pre-formtted in the form nd to the dt elements of the checklist. Two mesures were given for this ssessment: completeness rte nd comprehensiveness rte. Completeness rte ws defined s the proportion of completed items to the totl items in form. It reflects the extent to which dt items in form were completed y nurse. A formul for clculting the completeness rte of form is: Completeness rte (%) = the numer of items completed in the form the totl numer of items designed in the form 100 However, s different form formts my hve vrying numers of items; high completeness rte of form my not necessrily men tht more dt were cptured in this form thn nother one. Therefore, second prmeter, comprehensiveness rte ws used to cpture the proportion of completed items in form to the totl dt elements in the checklist. It reflects the mount of dt documented y nurse reltive to the full rnge of informtion defined in the checklist sed on prctice. This mesure llows the comprison of mount of dt recorded in different formts of forms. A formul for clculting the comprehensiveness rte of form is: Comprehensiveness rte (%) = the numer of items completed in the form the numer of dt elements in the checklist (105) 100 Both completeness rte nd comprehensiveness rte were clculted in overll nd t individul informtion ctegory levels to provide generl nd specific ssessment of completion sttus of different dmission forms. A comprison ws mde of the completeness nd comprehensiveness rtes for the different form formts. Comprison of ech rte ws mde for ny two of the seven formts. A similr comprison ws mde etween the overll rtes for ll pper-sed forms nd ll EHRs. In ddition, the frequency proportion of documenttion of ech dt element ws used s further mesurement of documenttion for comprison etween the pper-sed nd electronic dmission forms. It ws defined s the rtio of occurrences of documenttion of ech dt element to the numer of forms nlysed. This mesure reflected wht items were frequently or infrequently collected y the nurses in the pper-sed nd electronic dmission forms. A formul for clculting the frequency proportion of dt element mong the smples is: Frequency proportion = the numer of occurrences of documenttion mong the forms the numer of forms 100 Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

4 IJB-2938; No. of Pges 12 4 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx Tle 1 Ctegories nd dt elements of the checklist. Ctegories (numer of dt elements) Dt elements Resident demogrphics (n = 16) Title, full nme, preferred nme, dte of irth, ge, resident usul ddress, resident phone numer, gender, primry lnguge, secondry lnguge, interpreter needed, religion, mritl sttus, country of irth, originl or Torres Strit Islnder, working compny Admission detils (n = 16) Aged cre fcility, room, ed, loction, mediction trolley, photo tken dte, other informtion, medicl record numer, resident sttus (e.g. ctive), entry type, dmission dte, dmitted from/source of referrl, resident ctegory, UR numer, medicl record numer Resident helth history (n = 9) Allergies (drugs/other), medicl/surgicl dignosis, psychitric history, other conditions, drugs on dmission/mediction notes, flu vccintion, chest X-ry, externl cuse of injury or poisoning, plce of occurrence Bseline helth rnges (n = 4) Height, weight, lood sugr level, lood pressure Memership detils (n = 16) Pension type, pension/enefit cre numer Centrelink numer DVA crd numer or DVA crd memer numer) Nme s it ppers on the crd, expiry dte Privte helth insurnce provider/fund nme, memership numer/tle Amulnce fund (y/n), memer numer, trnsport ccess scheme Hospitl of choice, dietic ssocition numer, electorl roll (Yes/No), wr service End of life wishes (n = 5) Funerl rrngement (cremtion/uril), funerl director/undertker, phone numer, dvnced cre directive (Yes/No), summry of wishes/requirements Doctor (n = 5) Medicl officer nme, ddress, phone, emil, fx Generl contct (n = 18) Primry contct nme, reltionship, ddress, phone, emil, fx Secondry contct nme, reltionship, ddress, phone, emil, fx Next of kin 1 nme, reltionship, ddress, phone, emil, fx Legl contct (n = 13) Power of ttorney type, power of ttorney nme, ddress, power of ttorney phone numer, emil Gurdinship type (pulic/privte), nme, ddress, phone, emil Loction of will, solicitor, phone Completion of form (n = 3) Nme of person/nurse who completed the form on dmission, signture, dte 2.8. Dt nlysis Rw dt were entered into n Excel spredsheet, nd then imported into SPSS file (softwre 18.0) for sttisticl nlysis. Sttisticl methods used included descriptive sttistics nd non-prmetric sttisticl nlysis. The completeness nd comprehensiveness rtes of dmission forms were exmined y the Kruskl Wllis H test to identify ny sttisticlly significnt differences mong the seven formts. If significnt difference ws identified, the Mnn Whitney U test ws used for the identifiction of significnt differences etween ny two of seven form formts. In ddition, nonprmetric correltion nlysis with Spermn s rho test ws used to exmine the ssocitions etween the numers of items nd the completeness rte nd comprehensiveness rte of form formt in totl nd t ech informtion ctegory level. As nonprmetric tests were conducted, sttisticl dt presented in the pper re medin vlues. The mesurement results re presented s percentge of vlues. 3. Results 3.1. The use nd chrcteristics of different formts of resident dmission forms mong ged cre fcilities A totl of 399 dmission forms ws collected from the nine ged cre fcilities. There were six formts of pper-sed dmission forms nd two formts of electronic dmission forms. As one pper-sed form formt ws only used for one resident, it ws excluded from the nlysis, leving 398 forms in seven formts for the finl nlysis. A summry of the formt of forms used y the prticipting orgnistions nd fcilities is displyed in Tle 2. Six out of ten ctegories of dt items were common to ll types of forms. They include demogrphics, dmission detils, helth history, memership, doctor nd generl contct. e-form 6 ws n utomtion of pper-sed Form 3 nd e- Form 7 ws n utomtion of Form 5. However, oth electronic formts hve dditionl items to those in the pper-sed formts from which they were derived. e-form 6 hd 11 items in ddition to the 68 items in Form 3. e-form 7 derived 40 out of 47 items from Form 5 nd hd 27 dditionl items. The numer of items in ech formt of the dmission forms is presented in Tle Completeness of documenttion mong different formts of dmission forms nd etween pper-sed records nd EHRs The medin overll completeness rtes rnged from 38.1% (n = 18) for pper-sed Form 2 to 59.7% (n = 28) for e-form 7. The differences in completeness rtes mong the seven formts ws significnt (p < 0.01). A comprison of ny two of the seven form formts showed significnt differences in 13 out of 21 pirs (p < 0.05). Significnt differences in completeness rtes were found mong the seven form formts for ll of the informtion ctegories (p < 0.05) except seline helth rnges nd legl contct. A comprison of completeness rtes ws lso mde etween ny two of seven form formts t ech informtion Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

5 IJB-2938; No. of Pges 12 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx 5 Tle 2 Admission form formts nd the numer of smples. Fcility Orgnistion 1 Orgnistion 2 Orgnistion 3 A B C D E F G H I Form 3 (n = 7) Form 3 (n = 5) Form 2 (n = 6) Form 1 (n = 8) Form 1 (n = 35) Form 3 (n = 1) Form 4 (n = 15) Form 1 (n = 8) Form 2 (n = 1) n/ Form 5 (n = 28) Form 1 (n = 22) Form 2 (n = 11) Pper-sed dmission form formt (smple size n = 147) n/ e-form 6 (n = 39) e-form 6 (n = 40) e-form 6 (n = 25) e-form 6 (n = 36) e-form 6 (n = 11) e-form 6 (n = 34) e-form 6 (n = 38) e-form 7 (n = 28) Electronic dmission form formt (smple size n = 251) ctegory level. The results showed tht 94 out of 154 pirs (61%) hd significnt differences (p < 0.05) (Tle 3). The overll completeness rte in the electronic formts of dmission forms ws slightly higher thn tht in ppersed formts of forms (59.5%, interqurtile rnge 0.14 versus 55.8%, interqurtile rnge 0.10, p < 0.01). At the level of ech informtion ctegory, sttisticlly significnt increse in completeness rte ws found in electronic forms for severl informtion ctegories (p < 0.01). The gretest differences in completeness rte etween the electronic nd pper forms were in the ctegories of Helth History (incresed 23.8%); Memership (incresed 21.8%) nd Demogrphics (incresed 9.0%). In contrst, there ws reduced completeness rte in the electronic dmission forms in comprison with the pper forms in the informtion ctegory of Generl Contct y 14.2%. There ws no sttisticlly significnt difference etween the two types of forms in the ctegories of End of Life Wishes, Doctor nd Legl Contct. As e-form 6 nd e-form 7 were the utomtion of Form 3 nd Form 5, respectively, comprison of completeness rte of their common items (68 nd 40, respectively) within ech pir ws conducted. The results showed tht the completeness rtes of the two formts of electronic dmission forms were significntly higher thn tht of their counterprts (p < 0.01) (Fig. 1) Comprehensiveness of documenttion in the pper-sed records nd EHRs Vrition in the comprehensiveness rte ws found mong different form formts in totl nd for ech informtion ctegory (Tle 3). The overll comprehensiveness rtes for seven formts rnged from 21% for Form 5 to 41% for e-form 6. The difference mong them ws significnt (p < 0.01). A comprison of the overll comprehensiveness rte etween ny two of the seven form formts indicted tht 17 out of 21 pirs of forms hd sttisticlly significnt differences (p < 0.05). Specific comprison etween ny two of seven form formts t ech informtion ctegory level showed tht 145 out of 210 pirs of forms (69%) for n informtion ctegory hd sttisticlly significnt differences (p < 0.05). A sttisticlly significnt increse in the overll comprehensiveness rte ws found in the dmission forms in the EHRs compred with pper-sed forms (40.0% versus 28.6%, p < 0.01). At the level of informtion ctegory in form, significnt increses (p < 0.01) in the electronic forms were found in the dt ctegories of Admission Detils, Bseline Helth Rnges, Memership, Demogrphic, nd Generl Contct. There ws significnt decrese with Completion of Form nd Helth History (p < 0.01). No chnge ws found in the ctegories of Doctor nd Legl Contct. The difference for the ctegory End of Life Wishes ws not significnt. Fig. 2 presents the comprison of men comprehensiveness rtes etween pper-sed nd electronic dmission forms in totl nd y informtion ctegories. Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

6 Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012), Tle 3 Distriution of medin completeness nd comprehensiveness rtes (%), nd numers of items per form mong different form formts. Informtion ctegory Form 1 Form 2 Form 3 Form 4 Form 5 e-form 6 e-form 7 Totl pper-sed Totl EHRs Smple size Demogrphics Completeness rte (IQR) 73 (9) 81 (16) 70 (35) 89 (22) 89 (22)c 91 (9)d 86 (18)e 82 (16)A 91 (9)B Numer of items in the form Comprehensiveness rte (IQR) 50 (6) 44 (13) 43 (22)c 50 (6)ce 50 (13)c 63 (6)d 59 (13)de 50 (13) 63 (6) Admission detils Completeness rte (IQR) 75 (0)cd 100 (0) 75 (0) 67 (0)cd 100 (0)d 80 (0)c 83 (0)d 75 (0)A 80 (0)B Numer of items in the form Comprehensiveness rte (IQR) 25 (0) 19 (6) 56 (6)c 19 (6)d 19 (5)e 69 (6)f 31 (0)g 25 (6)A 69 (6)B Helth history Completeness rte (IQR) 36 (14) 50 (50) 100 (8)c 33 (0)d 100 (38)ce 67 (0)f 67 (0)fg 43 (33)A 67 (0)B Numer of items in the form Comprehensiveness rte (IQR) 44 (11) 17 (11) 22 (11)cd 22 (11)cd 22 (0)c 22 (0)d 30 (0)e 33 (22) 22 (0) Bseline helth rnges Completeness rte (IQR) n/ n/ n/ n/ n/ 20 (40) n/ n/ 20 (40) Numer of items in the form n/ n/ n/ n/ n/ 5 n/ n/ 5 Comprehensiveness rte (IQR) n/ n/ n/ n/ n/ 25 (50) n/ n/ 25 (100) Memership Completeness rte (IQR) 17 (0) 50 (33) 31 (12)c 33 (33)cd 20 (20)e 38 (23)f 29 (12)cg 17 (17)A 38 (23)B Numer of items in the form Comprehensiveness rte (IQR) 13 (0) 19 (13)d 25 (16)ce 19 (19)c 13 (13)d 31 (19)e 31 (13)e 13 (6)A 31 (19)B End of life wishes Completeness rte (IQR) 100 (0) 40 (2) 50 (0)c 67 (3)d n/ 50 (5)d n/ 67 (5)A 50 (5)A Numer of items in the form n/ 2 n/ 2 2 Comprehensiveness rte (IQR) 4 (0) 40 (20) 20 (0)c 40 (20)e n/ 20 (2)e n/ 40 (40)A 20 (20)A Doctor Completeness rte (IQR) 60 (4) 13 (1) 33 (2)c 75 (3)d 0 (0)e 33 (0.2)f 1 (0)g 40 (6)A 50 (2)A Numer of items in the form Comprehensiveness rte (IQR) 40 (2) 40 (2) 40 (3)c 60 (4) 40 (0)c 40 (2) 1 (0)d 40 (20)A 40 (20)B Generl contct Completeness rte (IQR) 78 (11) 28 (40) 57 (0.21)cf 53 (29)cdf 70 (38)ce 57 (24)f 63 (13)cfg 71 (42)A 57 (23)B Numer of items in the form Comprehensiveness rte (IQR) 44 (6) 36 (24)c 50 (19) 50 (22)d 22 (0)c 55 (22) 44 (0)d 39 (22)A 50 (22)B Legl contct Completeness rte (IQR) n/ 0.35 (0.20) 0 (0) 0 (0.3) 0.17 (0.3) 0 (1.0) 0 (0.3) 0 (30)A 0 (100)A Numer of items in the form n/ Comprehensiveness rte (IQR) 0 0 (15)c 0 (0) 8 (0.15)c 8 (8)c 0 (23)c 0 (8)d 0 (0)A 0 (0)B Completion of form Completeness rte (IQR) 100 (0) 100 (0) n/ n/ 50 (0)c n/ n/ 1 (1) n/ Numer of items in the form 1 3 n/ n/ 2 n/ n/ 1 n/ Comprehensiveness rte (IQR) 33 (33) 1 (42) n/ n/ 33 (0)c n/ n/ 33 (33) n/ Totl Completeness rte (IQR) 60 (10)d 38 (11) 56 (6)c 51 (22)ce 52 (16)c 59 (11)d 60 (8)de 56 (14)A 59 (11)B 6 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx IJB-2938; No. of Pges 12

7 IJB-2938; No. of Pges 12 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx 7 Tle 3 (Continued) Informtion ctegory Form 1 Form 2 Form 3 Form 4 Form 5 e-form 6 e-form 7 Totl pper-sed Totl EHRs Numer of items in the form Comprehensiveness rte (IQR) Letters refer to comprisons of completeness nd comprehensiveness rtes for different form formts. The sme letter for vlues from different forms indictes tht there ws no significnt difference etween them. Different letters for vlues indicte there ws significnt difference in the rtes. The sme pproch hs een used in comprison of rtes for the totl pper sed nd totl EHRs. IQR: interqurtile rnge. Vlues for numer of items in the two totls columns re the mens of vlues from the seven Form columns Frequencies of documented items in dmission forms etween pper-sed records nd EHRs Items of the dmission forms were put into seven groups ccording to their frequency of documenttion mong the smple forms. Sixteen dt elements were frequently recorded (frequency > 70%) nd 44 were infrequently recorded (frequency < 30%) in oth documenttion systems. Some dt elements were frequently recorded in pper-sed forms, ut were seldom present in EHRs forms, or vice vers (Tle 4) Assocition etween the numer of items nd the completeness rte nd comprehensiveness rte of dmission forms At the level of ech informtion ctegory, the negtive ssocition etween the completeness rte nd the numer of items designed in form ws sttisticlly significnt for pper-sed forms (see Tle 4, correltion coefficient 0.26, p < 0.001). This suggests tendency tht incresing the numer of items is ssocited with decresed completeness rte. No such tendency ws identified in electronic dmission forms. The ssocitions etween the comprehensiveness rtes nd the numer of items in form were highly significntly positive t n overll nd ech informtion ctegory levels in oth pper-sed nd electronic dmission forms (see Tle 5). This my suggest tht incresing the numer of items in form is ssocited with incresed mount of dt collected. 4. Discussion This study used qulittive pproch to derive checklist of resident dmission dt tht covers ll of the informtion items in seven dmission forms used in nine ged cre fcilities. The qulity of documenttion of pper-sed nd electronic resident dmission forms ws quntittively mesured nd compred to reflect the extent to which resident dmission dt were recorded. The mesurement ws undertken t three levels in ech form: overll, y informtion ctegory nd y individul dt element. Three mesures were used in the study: completeness rte, comprehensiveness rte nd the frequency proportion of documented dt element. Additionlly, the ssocitions etween the numer of items nd their completeness nd comprehensiveness rtes were identified t overll nd informtion ctegory levels for ll the forms nd etween pper-sed nd electronic systems. The study identified vrying prctice mong the prticipting ged cre orgnistions in the documenttion of resident ckground informtion in the dmission forms. In the previous pper-sed documenttion systems, different formts of dmission forms were used cross the three ged cre orgnistions. Within ech orgnistion, the formt of the dmission forms could lso e different cross the fcilities or within ech fcility. In Orgnistion 2, Form 1 ws used in Fcility E nd Form 2 in Fcility F, while oth these forms were used in Fcilities C nd D. Form 1 ws issued under the Nursing Fcilities Act 1988 nd ws used for residents dmitted efore Form 2 ws designed y the orgnistion nd ws introduced lter. Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

8 IJB-2938; No. of Pges 12 8 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx 100 Men completeness rte (%) Pper-sed Electronic Form 3 vse-form 6 Form 5 vse-form 7 Note: the r on the top of histogrm is stndrd error Fig. 1 Comprison of men completeness rtes of common items etween the pper-sed nd electronic dmission forms y ech pir. Note: the r on the top of histogrm is stndrd error. This reflected chnge of the documenttion prctice in the orgnistion over time. In Orgnistion 3, oth Fcilities H nd I used Form 3, while Fcility G used Forms 1, 3 nd 4. The reson for this is tht Fcility G ws previously under different mngement nd jointed Orgnistion 3 in the ltter stge. Therefore, different formt of forms ws found in the fcility for the older people who were dmitted t different stges. On the other hnd, the implementtion of the EHR hs stndrdised the formt of resident dmission forms in Orgnistions 2 nd 3. This should support communiction nd exchnge of informtion etween different orgnistions nd fcilities nd the use of dt for vrious purposes. We found tht the electronic dmission forms hd etter completeness nd comprehensiveness rtes thn pper-sed forms. This evidence ws further supported y comprison of completeness rtes etween the common items in two pirs of pper-sed nd their electronic derivtives. A higher completeness rte in the electronic forms my suggest tht the EHRs were more convenient for the nurses to enter dt items thn using the pper-sed record systems. This result is consistent with the previous findings tht the use of EHRs ws conducive to more complete documenttion y helth cre professionls [12]. An incresed comprehensiveness rte in electronic dmission forms suggests tht more resident dmission dt were contined in the EHRs. This should fcilitte nurses nd other cre stff in conducting risk ssessment nd plnning more pproprite cre to the residents. Despite the enhnced qulity of documenttion of resident dmission dt in the EHRs, the overll completeness nd comprehensiveness rtes for oth pper-sed nd electronic dmission forms were not high. In regrd to the completeness rte, only out 56% of items in the pper-sed forms nd 60% Men comprehensiveness rte (%) Pper-sed Electronoc 10 0 Informtion ctegory Note: the r on the top of histogrm is stndrd error Fig. 2 Comprison of men comprehensiveness rtes of dmission forms etween pper-sed records nd EHRs in totl nd y informtion ctegories. Note: the r on the top of histogrm is stndrd error. Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

9 IJB-2938; No. of Pges 12 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx 9 Tle 4 Admission form items nd groups y level of frequency of documenttion (n = 251 electronic versus 147 pper-sed dmission forms). Group Items Items with high frequency of documenttion (>70%) in oth pper-sed nd electronic forms Items with low frequency of documenttion (<30%) in oth pper-sed nd electronic forms Items with high frequency of documenttion (>70%) only in electronic forms Items with high frequency of documenttion (>70%) only in the pper-sed forms Items with low frequency of documenttion (<30%) only in the electronic forms. Items with low frequency of documenttion (<30%) only in the pper-sed forms Items with frequency etween 30% nd 70% in oth pper-sed nd electronic forms Full nme, DOB, gender, religion, mritl sttus, country of irth, ged cre fcility, dmission dte, llergies, medicl/surgicl dignosis, Medicre crd numer, doctor nme, primry contct nme, primry contct reltionship, primry contct ddress, primry contct phone, next of kin nme, next of kin reltionships, next of kin ddress, next of kin phone no. Resident phone numer, secondry lnguge, interpreter needed, working compny, other informtion, resident UR numer, medicl record numer, externl cuse of injury nd poisoning, plce of occurrence of injury, flu vccintion, chest X-ry, psychitric history, weight, lood sugr level, lood pressure, pension/enefit cre numer, Austrlin DVT crd numer, hospitl insurnce, privte helth insurnce provider, privte helth insurnce/fund numer/tle, mulnt fund, dietes ssocition numer, election roll, wr service, funerl directive phone numer, dvnced cre directive, summry of wishes, doctor ddress, doctor emil, primry nd secondry contct nd next of kin s emil nd fx, power of ttorney s ddress nd emil, gurdinship s nme, ddress, phone nd emil, loction of will, solicitor s nme nd phone numer, nme of nurse completing the form Title, preferred nme, primry lnguge, originl or Torres Strit Islnder, diet, room, loction, mediction trolley, dmission sttus, entry type, resident ctegory, funerl rrngement, doctor phone None Age, resident usul ddress, dmitted from/source of referrl, other helth condition present, drugs on dmission Title, preferred nme, diet, room, ed, loction, mediction trolley, photo tken, dmission sttus, entry type, resident ctegory, cre recipient ID, height, Centrelink numer, Medicre crd memer numer, nme s it ppers on Medicre crd, Medicre crd expiry dte, trnsport ccess scheme, doctor fx, secondry contct nme, secondry contct reltionship, secondry contct ddress, secondry contct phone numer, power of ttorney type, power of ttorney nme, power of ttorney phone numer Pension type, funerl director/undertker of those in the EHRs were recorded. The overll comprehensiveness rte ws lso low for oth pper-sed nd electronic forms (29% nd 40%, respectively). In the prticipting RACFs, resident dmission form ws usully documented y registered nurse (RN) or sometimes y n endorsed enrolled nurse (EEN) in the nursing sttion when the resident ws first dmitted into the fcility. Documenttion could lso e conducted y nursing mnger in the office. Incomplete documenttion cn reflect the nurses poor documenttion ehviour nd implies tht the reliility nd vlidity of the informtion source is compromised [5], indicting need for improvement. The qulity of nursing documenttion is determined y three chrcteristics: documenttion structure nd formt, documenttion process nd documenttion content [21]. Low completeness nd comprehensiveness rtes of nursing records identified in this study in oth the pper-sed nd electronic forms could e cused y the fctors relted to the three interrelted chrcteristics of qulity of documenttion nd need to e effectively ddressed y documenttion system. In regrd to the structures of the two types of forms tht could determine dt entry, the pper-sed forms provided the opportunity for nurse to enter severl types of Tle 5 Correltions etween the numer of items in form nd the completeness nd comprehensiveness rtes of the form. Correltion vriles Pper-sed dmission forms Electronic dmission forms Correltion coefficient p vlue Correltion coefficient p vlue Totl numer of items versus overll completeness rte Numer of items versus completeness rte for ech ctegory Totl numer of items versus overll comprehensiveness rte Numer of items versus comprehensiveness rte for ech ctegory < < < < <0.001 Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

10 IJB-2938; No. of Pges i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx dt: writing free-text dt, selecting nswers from severl pre-formtted nswers with tick ox, or selecting yes or no option to question. In the electronic medium, free-text field for nurse to type in dt ws ville for most items. For some items, nurse cn select nswers from drop-down list or tick ox of nswers, choose yes or no options y rdio uttons. In terms of documenttion process, some nurses poor typing skill nd inility to use the system competently might e the impediment for them to enter dt in the computer, with the direct consequence of incomplete documenttion. In this sitution, providing trining to nurses to improve their skills in using electronic systems should e helpful. Incresing nurses ccess to the records y plcing computers in convenient loction in the wrds my lso fcilitte the documenttion process. In reltion to the content of documenttion, lck of relevnce of some dt items to resident s specific sitution could e the reson for incomplete documenttion. Defining relevnt nd dequte dt items is essentil to encourge documenttion. Poor comprehensiveness rte could e cused y the vrition in the numer nd types of dt items mong different form formts, which hd resulted in incresed numer of dt elements in the checklist. Differences in the formts nd dt items in vrious dmission forms used in different ged cre orgnistions lso rise the question of which dt items re essentil for collecting relevnt resident dt to meet cre nd mngement purposes. Unnecessry items in the forms might compromise the privcy of residents nd dd to nurses documenttion worklod, thus eing counter-productive through discourging nursing stff to document. Resident dmission forms contined wide rnge of informtion concepts under 10 ctegories. It ppers tht certin items tended to e recorded more often thn the others. Frequently collected dt items were minly under the ctegories of demogrphic, generl contct nd dmission detils for oth pper-sed nd electronic forms. Poorly documented dt items in oth pper-sed nd electronic forms were minly under the ctegories of memership nd legl contct. The low completeness could lso e cused y the inpplicility of some items to resident s sitution, ut the nurses needed to t lest document n/ or nil in the dt fields to inform the messge receivers tht the informtion items hd een reviewed. As mny older people in RACFs hve poor cognitive cpcity [22], incomplete documenttion of essentil informtion out them my led to nurses lck of comprehensive understnding out the older people s needs nd the provision of su-optiml cre to them. The items under the ctegory of seline helth rnges, which were dded to one of the EHRs eing widely used in seven fcilities, were poorly completed. On the other hnd, items such s History of Injury, Flu Vccintion, Chest X- ry, Psychitric Dignoses were not formtted in this new EHR. A lck of this informtion in the current electronic forms my confine the plnning of pproprite cre to the residents. The solution for this prolem my e recording them in other sections of the EHRs such s ssessment forms, ut this my cuse confusion to nurses when retrieving the informtion for immedite use in plnning cre. Redundncy of documenttion could lso e concern if these dt were stored in other sections of the systems. Completeness rte nd comprehensiveness rte mesured different concepts in this study. Completeness rte cn only indicte the extent to which items in form re documented y nurse when different formts of forms re compred. A form with higher completeness rte, ut less items my not contin more informtion thn form with more items, ut lower completeness rte. It could reflect the usefulness of items in form or the nurses documenttion ehviour. On the other hnd, comprehensiveness rte cn tell how much informtion is collected in form reltive to common checklist nd therefore mkes different forms with vrying numer of items comprle. The results of the correltion nlysis descried ove my indicte tht for collecting the sme type of informtion in pper-sed form, incresing the numer of items could led to more dt to e cptured, though it might cuse nurses reluctnce to complete these items, thus resulting in decresed completeness rte of the forms. In contrry, oth completeness nd comprehensiveness (mount of informtion) were improved, regrdless of the numer of items. These reltionships etween the numer of items designed in form nd the completeness nd comprehensiveness rtes my provide implictions for the design of forms. The study hs lso identified issues with coding or terminologies in pper-sed forms. For exmple, in Form 1 under the informtion ctegory of Helth History, severl items were designed to cpture informtion out resident s different dignoses. The menings of these items could e overlpped or vgue to nurses nd this might e the reson for the low completeness rte for this informtion ctegory (36%). Another exmple is tht items referring to the sme concept were given different nme in different form formts. For instnce, Doctor ws nmed s Physicin, Medicl Doctor, Generl Prctitioner, or Medicl Officer in different forms. Appliction of stndrdised terminology would ensure the semntic interoperility of EHRs for communiction etween systems [23]. There re severl limittions to the study. The dmission forms were conveniently collected from nine ged cre fcilities in three orgnistions. As there ws reltively consistent pproch to the documenttion in ech of ged cre orgnistion, our results re representtive of the documenttion prctice within the prticipting fcilities or orgnistions. However, the results my not fully reflect the prctice of recording resident dmission dt in other ged cre fcilities or orgnistions. Another limittion is tht the development of the checklist nd the nlysis of dt did not tke into ccount ny mndtory fields of the dmission forms. It ws ssumed tht ll of the items in form should e documented, though some items such s Additionl Informtion might not e necessry. There re lso items such s those out secondry nd legl contct nd memership detils, which might not e pplicle for every resident. These items could e considered s not mndtory, thus distinction etween not documented nd not pplicle could improve the ccurcy of this study; however, this informtion ws difficult to retrieve ecuse it ws impossile to hve direct contct with the residents nd we could not identify cler guideline Plese cite this rticle in press s: N. Wng, et l., Description nd comprison of qulity of electronic versus pper-sed resident dmission forms in Austrlin ged cre fcilities, Int. J. Med. Inform. (2012),

11 IJB-2938; No. of Pges 12 i n t e r n t i o n l j o u r n l o f m e d i c l i n f o r m t i c s x x x ( ) xxx xxx 11 for nursing documenttion in the prticipting orgnistions. This lck of considertion of the difference etween mndtory nd optionl fields my hve resulted in low rnking of qulity of documenttion for some forms. Moreover, the study focused on the occurrence of documenttion nd did not consider wht hd een recorded. This could cuse is to the study results if inconsistent or inccurte informtion hd een recorded. 5. Conclusion Vrying documenttion prctice existed with previous ppersed systems in collecting resident dmission informtion. The implementtion of the electronic nursing documenttion system stndrdised vrious formts of pper-sed dmission forms cross the ged cre fcilities nd orgnistions. It lso contriuted to etter qulity of documenttion of resident dmission forms, cler enefit of using EHRs in the ged cre fcilities. However, the resident dmission forms in the EHRs were still incomplete, implying need for further improvement in documenttion prctice. This study nlysed the dt coverge of different dmission forms nd their completeness oth in generl nd in different informtion ctegories. The reserch finding cn inform etter design of electronic forms. Further studies re needed on wht informtion is essentil to collect from residents on their dmission; wht fctors led to incomplete documenttion in dmission forms; wht fctors cuse vrying documenttion prctices nd wht is the impct of poor documenttion on the qulity of cre nd sfety of residents. Authors contriutions Ning Wng, Ping Yu nd Dvid Hiley contriuted to the conception nd design of the study. Dt collection, nlysis nd interprettion were done y Ning Wng. Ning Wng prepred the first drft of the mnuscript. Ning Wng, Ping Yu nd Dvid Hiley criticlly revised the importnt intellectul content of the mnuscript. All uthors pproved the finl mnuscript for sumission. Conflict of interest The uthors clim tht there is no conflict of interest with conduction of the study. Acknowledgements The study is prt of rod reserch project funded y the Austrlin Reserch Council nd five ged cre orgnistions in Austrli. The uthors would like to thnk the residents nd their representtives for giving consent for the reserch tem to collect nd nlyse their records in this study. The uthors would lso like to cknowledge nurses, nursing mngers nd mngement groups of the prticipnt ged cre orgnistions for giving the reserch tem support nd ccess to the ged cre fcilities to collect reserch dt. Summry points Wht ws known efore this study As n importnt dt source for dministrtive purposes nd cre plnning in ged cre fcilities, the qulity of resident dmission forms hs rrely een investigted y reserchers. Poor documenttion of ptient dmission informtion in n cute setting with pper-sed system nd EHRs hs een identified y previous studies. 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