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

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission jo u r n al h o m e p a g e :w w w . i j m i j o u r n a l . c o m

Description

and

comparison

of

quality

of

electronic

versus

paper-based

resident

admission

forms

in

Australian

aged

care

facilities

Ning

Wang,

Ping

Yu

∗

,

David

Hailey

HealthInformaticsResearchLaboratory,SchoolofInformationSystemsandTechnology,FacultyofInformatics,UniversityofWollongong, Australia

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received29September2011

Receivedinrevisedform

23October2012

Accepted16November2012

Keywords:

Admissionform

Auditing

Electronichealthrecord

Electronicrecord Evaluation Nursingdocumentation Paperrecord Quality

a

b

s

t

r

a

c

t

Purpose:Todescribethepaper-basedandelectronicformatsofresidentadmissionforms

usedinseveralagedcarefacilitiesinAustraliaandtocomparetheextenttowhichresident

admissioninformationwasdocumentedinpaper-basedandtheelectronichealthrecords.

Methods:Retrospectiveauditingandcomparisonofthedocumentationqualityof

paper-basedandelectronicresidentadmissionformswereconducted.Achecklistofadmission

data wasqualitativelyderivedfromdifferentformatsoftheadmissionforms collected.

Threemeasureswereusedtoassessthequalityofdocumentationoftheadmissionforms,

includingcompletenessrate,comprehensivenessrateandfrequencyofdocumenteddata

element.Theassociationsbetweenthenumberofitemsandtheircompletenessand

com-prehensivenessrateswereestimatedatagenerallevelandateachinformationcategory

level.

Results: Variouspaper-based andelectronic formatsofadmissionforms werecollected,

reflectingvaryingpracticeamongtheparticipantfacilities.Theoverallcompletenessand

comprehensivenessratesoftheadmissionformswerepoor,butwerehigherinthe

elec-tronic healthrecordsthaninthepaper-basedrecords(60%versus56%and40%versus

29%respectively,p<0.01).Thereweredifferencesintheoverallcompletenessand

com-prehensivenessratesbetweenthedifferentformatsofadmissionforms(p<0.01).Ateach

informationcategorylevel,varyingdegreesofdifferenceinthecompletenessand

compre-hensivenessrateswerefoundbetweendifferentformformatsandbetweenthepaper-based

andtheelectronicrecords.Anegativeassociationbetweenthecompletenessrateandthe

number ofitemsina formwasfoundateachinformationcategorylevel(p<0.01), i.e.,

moredataitemsdesignedinaform,thelesslikelythattheitemswouldbecompletely

filled.However,theassociationsbetweenthecomprehensivenessratesandthenumber

ofitemswerehighlypositiveatbothoverallandindividualinformationcategorylevels

(p<0.01),suggestingmoreitemsdesignedinaform,moreinformationwouldbecaptured.

∗ _{Correspondingauthorat:HealthInformaticsResearchLaboratory,SchoolofInformationSystemsandTechnology,FacultyofInformatics,}

UniversityofWollongong,NorthfieldsAve,Wollongong,NSW2522,Australia.Tel.:+61242215412;fax:+61242214045.

E-mailaddress:ping@uow.edu.au(P.Yu).

1386-5056/$–seefrontmatter©2012ElsevierIrelandLtd.Allrightsreserved.

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission formsinAustralianagedcarefacilities,Int.J.Med.Inform.(2012),http://dx.doi.org/10.1016/j.ijmedinf.2012.11.011

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international journal of medical informatics xxx (2012)xxx–xxx

Conclusion:Betterqualityofdocumentationinresidentadmissionformswasidentifiedin

theelectronicdocumentationsystemsthaninpreviouspaper-basedsystems,butstillneeds

tobefurtherimprovedinpractice.Thequalityofdocumentationofresidentadmissiondata

shouldbefurtheranalysedinrelationtoitsspecificcontent.

©2012ElsevierIrelandLtd.Allrightsreserved.

1.

Introduction

The importance of information about clients and care in

theoperationofmodernhealthcareorganisationshasbeen

wellrecognised[1–3].Informationsystemsthatfacilitatedata

collection and tracking for patient care can also sustain

carequalityimprovement[4].In thepastdecades,

applica-tionofelectronichealthrecords(EHRs)hasstreamlineddata

processing and management in many health caresettings

withbenefitsofincreasingaccesstomorecomplete,accurate

andup-to-datedataandreducingredundancy[1,5–7].Inaged

caresettings,theimplementation ofEHRshaspotential to

improvequalityofcare,efficiencyofoperationandintegration

ofservices[4].

Giventhefundamentalsignificanceofnursing

documenta-tioninAustralianagedcaresectorforthepurposesoffunding,

accreditationand quality improvement[8–10], several aged

careorganisationsinAustraliahaveimplementedEHRs.

Care-giversperceived the benefitsofthe implementation ofthe

EHRsastheprovisionofmoreaccurate,legibleandcomplete

informationandreductionofrepetitionindataentry[11].In

thispaper,wereportanauditstudytoinvestigatetheactual

effectoftheEHRsonthequalityofnursingdocumentation.

Asasignificantpartofresidentrecordsinagedcare,

res-identadmissionformscontaininformationaboutresidents’

personalandhealthhistory,supportnetworksanddischarge

planning.Suchresidentdataareessentialforadministrative

purposes, resident assessment, and care planning. Quality

residentadmissiondatamayalsoplayavitalroleinservice

coordination,publichealthresearchandhealthplanning.

Numerous studies have been carried out to investigate

theimpactofEHRsontheinformationqualityofarangeof

documentationcomponentsandimprovedcompletenessof

documentationwithEHRshasbeen reported[12]. However,

moreomissionsanderrors intheEHRs werealsoreported

[13].Severalstudiesconductedinacutesettingshavereported

poorcompletenessofselectedelementsofadmission

infor-mation suchas admissiondiagnosis, allergies, medication,

occupation, socialclass,name/telephoneofcontactperson

andreligion[14–17].InregardtoEHRs,Prinsetal.[16]

iden-tifiedinadequatedocumentationofadmissiondiagnosesand

reasonforadmission.Pringleetal.’sstudy[18]showedthatthe

documentationofoccupationwasincompleteandno

infor-mationaboutsocialclassandethnicityhadbeenrecorded.In

addition,Floor-Schreuderingetal.[19]havereportedpoor

doc-umentationinEHRsofpatients’telephonenumbersanddrug

historyaftertheirfirstvisittoalocalpharmacy.

However,inadequateresearchattentionhasbeenpaidto

thequalityofoverall admissioninformation.Todate,there

hasbeenno studyon thequalityofadmissiondatainthe

agedcaresetting.Therefore,ourstudyinvestigatedthe

qual-ity ofresident admissiondata documentedinpaper-based

and electronic admissionforms in several agedcare

facil-ities from different organisations where commercial EHRs

hadbeenimplemented.Theobjectivesofthestudywereto

describethepaper-basedandelectronicformatsofresident

admissionformsusedintheagedcarefacilities;andto

com-paretheextenttowhichresidentadmissioninformationwas

documentedintheseformats.

2.

Methods

2.1. Studydesign

This was anursing documentation auditstudy.

Retrospec-tivereviewandcomparisonofthedocumentationqualityof

paper-based and electronic resident admissionforms were

conducted.

2.2. Setting

Thestudywascarriedoutatnineresidentialagedcare

facil-ities(RACFs)fromthreeagedcareorganisationsinAustralia

(codedasOrganisation1,2and3,respectively).These

orga-nisationshaveimplementedtwocommercialEHRsystemsat

differenttimepointssince2005:Software1wasimplemented

inOrganisation1andSoftware2wasimplementedin

Organi-sations2and3.

2.3. Sample

The study sampleswere the resident records conveniently

selectedfromthenineRACFs.Theseincluded251electronic

and147paper-basedresidentadmissionformsfromthe

resi-dentrecords.Thenumberofsamplesvariedamongthenine

facilitiesduetodifferencesinthenumberofresidentswho

gavetheirconsentandtheunavailabilityofarchived

paper-basedrecordsatsomefacilities.

2.4. Participants

Participantswere theresidentsoftheRACFswhose

admis-sionformswereaccessedbytheresearchersafterconsenthad

beenprovided.Beforeseekingwrittenconsent,aninformation

sheetwithdetaileddescriptionaboutthestudyincludingdata

handlingprocedureswasgiventotheresidentsortotheir

rep-resentatives,dependingontheresidents’cognitivecapacity.

2.5. Ethicsapproval

The study was approved by University of

Wollon-gong/Illawarra AreaHealth Service HumanResearch Ethics

Committeeandtheethicscommitteeofaparticipatingaged

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission 2.6. Developmentofanauditingchecklist

A checklist to compare the documentation quality of the

different admission form formats used by the RACFs was

developedusingdataelementsthatwerequalitativelyderived

fromtheadmissionformsusingasimilarapproachtothatof

Schleyeretal.[20].Thedifferentformatsofformsusedbythe

RACFssharedsomecommonitems,butvariedintheir

con-tent.Asthestudywasintendedtopresentafullpictureabout

thescopeofinformationtobecollectedfromtheresidentsby

usingtheadmissionforms,thechecklistincludedallitems

intheincludedadmissionforms,exceptthoseaboutresident

dischargeinformation.Discharge-relateditemswereexcluded

becausemostoftheparticipating residents’admission

sta-tus was current. Inclusion of all items from the different

admissionformsrecognised that they had been developed

andvalidatedbyexperiencednursingmanagersineachaged

careorganisation.Thusthe nursingknowledgecaptured in

theadmissionformswasvaluableandshouldberespected.

Duringthe developmentofthechecklist, all itemsfrom

eachformatoftheadmissionformswereextractedandthen

groupedintocategories.Undereachcategory,anyduplicated

itemsweremergedtoformasingledataelementforthe

check-list,includingitemsreferringtothesameconcept,butnamed

differently(e.g.,‘AdmissionDate’and‘DateofEntry’).

Foritemsdesignedtocollectsimilartypeofdatabutwith

differentlevelsofgranularityfromgeneraltospecific,a

sum-maryterm wasadoptedtoformasingledataelement.For

example,‘Medical/SurgicalDiagnosis’wasusedinthe

check-listforseveralitemssuchas‘ProvisionalDiagnosis’,‘Principal

Diagnosis’, ‘Principal Operation and Major Procedure’ and

‘OtherOperationsorProcedures’.Additionally,someseparate

itemsthatarerelatedtoeachotherwerecombinedtoasingle

dataelement.Forexample,‘Surname’and‘FirstName’were

combinedtoformadataelementof‘FullName’.

Thechecklistwasusedtodeterminewhetherornot

infor-mationonindividualitemshadbeenenteredintoindividual

admissionforms.Noattemptwasmadetodeterminewhether

theitemswereapplicabletoindividualsastheresearchersdid

nothavedirectcontactwiththeresidents.Norwasthe

qual-ityofnarrativeentriesforsomeitemsconsidered.Thevalidity

ofthechecklistwasbasedonhowwellitscontentscaptured

thedetailsfromalltheresidentadmissionformformats.The

checklistwasjudgedbythreehealthinformaticsresearchers

whoconsideredandreachedconsensusonthe

appropriate-nessofcategorisationoftheitems.Thechecklistcontained

10categorieswith105dataelements.Theseentirelycovered

thedataintendedtobecollectedbyvariousadmissionforms

fromresidentsattheiradmission.Detailedinformationabout

thechecklistisdisplayedinTable1.

Adichotomousscalewith‘yes/no’optionswasadoptedto

scoreeach admissionformdependingontheoccurrenceof

documentationforeachofthedataelements.Onepointwas

giventoa‘yes’optionandzerowasgiventoa‘no’opinion.Two

researchersagreedontheprotocolforratingtheadmission

formsandthengradedtheformsinthesamplefromtheRACFs

using the checklist spreadsheet listing the data elements.

Duringthisprocess,anyquestionordisagreementwas

dis-cussedtoreachconsensus.

2.7. Measurementapproaches

Quantitative description of documentation of admission

forms was made through mapping items completedin an

admissionformtotheitemspre-formattedintheformandto

thedataelementsofthechecklist.Twomeasuresweregiven

forthisassessment:completenessrateand

comprehensive-nessrate.

Completenessratewasdefinedastheproportionof

com-pleteditemstothetotalitemsinaform.Itreflectstheextent

towhichdataitemsinaformwerecompletedbyanurse.A

formulaforcalculatingthecompletenessrateofaformis:

Completenessrate(%)

= thenumberofitemscompletedintheform

thetotalnumberofitemsdesignedintheform×100

However,asdifferentformformatsmayhavevarying

num-bersofitems;ahigh completenessrateofaformmaynot

necessarilymeanthatmoredatawerecapturedinthisform

thananotherone.Therefore,asecondparameter,

comprehen-sivenessratewasusedtocapturetheproportionofcompleted

itemsinaformtothetotaldataelementsinthechecklist.It

reflectstheamountofdatadocumentedbyanurserelative

tothefullrangeofinformationdefinedinthechecklistbased

onpractice.Thismeasureallowsthecomparisonofamount

ofdatarecordedindifferentformatsofforms.Aformulafor

calculatingthecomprehensivenessrateofaformis:

Comprehensiveness rate(%)

= _thethe number_numberofdataofitems_elementscompleted_inthein_checklisttheform₍₁₀₅₎×100

Bothcompletenessrateandcomprehensivenessratewere

calculatedinoverallandatindividualinformationcategory

levelstoprovidegeneralandspecificassessmentof

comple-tionstatusofdifferentadmissionforms.

Acomparisonwasmadeofthecompletenessand

compre-hensivenessratesforthedifferentformformats.Comparison

ofeachratewasmadeforanytwoofthesevenformats.A

similarcomparisonwasmadebetweentheoverall ratesfor

allpaper-basedformsandallEHRs.

Inaddition,thefrequencyproportionofdocumentationof

each data element was usedas afurther measurementof

documentation for acomparisonbetween the paper-based

and electronicadmissionforms.Itwasdefinedasthe ratio

ofoccurrencesofdocumentationofeachdataelementtothe

numberofformsanalysed.Thismeasurereflectedwhatitems

werefrequentlyorinfrequentlycollectedbythenursesinthe

paper-basedand electronicadmissionforms.Aformulafor

calculatingthefrequencyproportionofadataelementamong

thesamplesis:

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission formsinAustralianagedcarefacilities,Int.J.Med.Inform.(2012),http://dx.doi.org/10.1016/j.ijmedinf.2012.11.011

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Table1–Categoriesanddataelementsofthechecklist.

Categories(numberof dataelements)

Dataelements

Residentdemographics(n=16) Title,fullname,preferredname,dateofbirth,age,residentusualaddress,residentphone number,gender,primarylanguage,secondarylanguage,interpreterneeded,religion,marital status,countryofbirth,aboriginalorTorresStraitIslander,workingcompany

Admissiondetails(n=16) Agedcarefacility,room,bed,location,medicationtrolley,phototakendate,otherinformation, medicalrecordnumber,residentstatus(e.g.active),entrytype,admissiondate,admitted from/sourceofreferral,residentcategory,URnumber,medicalrecordnumber

Residenthealthhistory(n=9) Allergies(drugs/other),medical/surgicaldiagnosis,psychiatrichistory,otherconditions,drugson admission/medicationnotes,fluvaccination,chestX-ray,externalcauseofinjuryorpoisoning, placeofoccurrence

Baselinehealthranges(n=4) Height,weight,bloodsugarlevel,bloodpressure

Membershipdetails(n=16) Pensiontype,pension/benefitcarenumber

Centrelinknumber

DVAcardnumberorDVAcardmembernumber) Nameasitappearsonthecard,expirydate

Privatehealthinsuranceprovider/fundname,membershipnumber/table Ambulancefund(y/n),membernumber,transportaccessscheme

Hospitalofchoice,diabeticassociationnumber,electoralroll(Yes/No),warservice

Endoflifewishes(n=5) Funeralarrangement(cremation/burial),funeraldirector/undertaker,phonenumber,advanced caredirective(Yes/No),summaryofwishes/requirements

Doctor(n=5) Medicalofficername,address,phone,email,fax

Generalcontact(n=18) Primarycontactname,relationship,address,phone,email,fax Secondarycontactname,relationship,address,phone,email,fax Nextofkin1name,relationship,address,phone,email,fax

Legalcontact(n=13) Powerofattorneytype,powerofattorneyname,address,powerofattorneyphonenumber,email Guardianshiptype(public/private),name,address,phone,email

Locationofwill,solicitor,phone

Completionofform(n=3) Nameofperson/nursewhocompletedtheformonadmission,signature,date

2.8. Dataanalysis

RawdatawereenteredintoanExcelspreadsheet,andthen importedintoaSPSSfile(software18.0)forstatistical anal-ysis.Statisticalmethodsusedincludeddescriptivestatistics and non-parametric statistical analysis. The completeness andcomprehensivenessratesofadmissionformswere exam-inedbytheKruskal–WallisHtesttoidentifyanystatistically significantdifferencesamongthesevenformats.Ifa signifi-cantdifferencewasidentified,theMann–WhitneyUtestwas usedfortheidentificationofsignificantdifferencesbetween anytwoofsevenformformats.

Inaddition,nonparametriccorrelationanalysiswith Spear-man’srhotestwasusedtoexaminetheassociationsbetween thenumbersofitemsandthecompletenessrateand com-prehensiveness rate ofaform formatin total and ateach informationcategorylevel.Asnonparametrictestswere con-ducted,statistical data presentedinthe paper are median values.Themeasurementresultsarepresentedaspercentage ofvalues.

3.

Results

3.1. Theuseandcharacteristicsofdifferentformatsof

residentadmissionformsamongagedcarefacilities

Atotalof399admissionformswascollectedfromthenine agedcarefacilities. There were sixformatsofpaper-based admission formsand two formats of electronic admission forms.As onepaper-based formformatwas onlyused for oneresident,itwasexcludedfromtheanalysis,leaving398

formsinsevenformatsforthefinalanalysis.Asummaryof theformatofformsusedbytheparticipatingorganisations andfacilitiesisdisplayedinTable2.

Sixoutoftencategoriesofdataitemswerecommontoall

typesofforms.Theyincludedemographics,admissiondetails,

healthhistory,membership,doctorandgeneralcontact.

e-Form6wasanautomationofapaper-basedForm3and

e-Form7wasanautomationofForm5.However,bothelectronic

formatshaveadditionalitemstothoseinthepaper-based

for-matsfromwhichtheywerederived.e-Form6had11itemsin

additiontothe68itemsinForm3.e-Form7derived40outof

47itemsfromForm5andhad27additionalitems.Thenumber

ofitemsineachformatoftheadmissionformsispresented

inTable3.

3.2. Completenessofdocumentationamongdifferent formatsofadmissionformsandbetweenpaper-based recordsandEHRs

The medianoverall completeness ratesranged from 38.1%

(n=18)forpaper-basedForm2to59.7%(n=28)fore-Form7.

Thedifferencesincompletenessratesamongtheseven

for-matswassignificant(p<0.01).Acomparisonofanytwoofthe

sevenformformatsshowedsignificantdifferencesin13out

of21pairs(p<0.05).

Significantdifferencesincompletenessrateswerefound

amongthesevenformformatsforalloftheinformation

cat-egories (p<0.05) except ‘baseline health ranges’ and ‘legal

contact’.

A comparison of completeness rates was also made

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission T able 2 – Admission form forma ts and the n u mber of samples. F acility Or g anisation 1 O rg anisation 2 Or g anisation 3 AB C D E F G H I P aper -based admission form format (sample size n = 147) n/a F orm 5 (n = 28) F orm 1 (n = 22) F orm 2 (n = 11) F orm 1 (n = 8) F orm 2 (n = 1) F orm 2 (n = 6) F orm 1 (n = 8) F orm 1 (n = 35) F orm 3 (n = 1) F orm 4 (n = 15) F orm 3 (n = 7) F orm 3 (n = 5) Electr onic admission form format (sample size n = 251) e-F orm 7 (n = 28) n/a e-F orm 6 (n = 39) e-F orm 6 (n = 40) e-F orm 6 (n = 25) e-F orm 6 (n = 36) e-F orm 6 (n = 11) e-F orm 6 (n = 34) e-F orm 6 (n = 38)

categorylevel.Theresultsshowedthat94outof154pairs(61%)

hadsignificantdifferences(p<0.05)(Table3).

Theoverall completenessrate inthe electronic formats

ofadmissionformswasslightlyhigherthan thatin

paper-basedformatsofforms(59.5%,interquartilerange0.14versus

55.8%,interquartilerange0.10,p<0.01).Atthelevelofeach

information category, a statistically significant increase in

completeness rate was found in electronic forms for

sev-eralinformationcategories(p<0.01).Thegreatestdifferences

in completeness rate between the electronic and paper

formswere inthe categories of‘HealthHistory’ (increased

23.8%); ‘Membership’ (increased 21.8%) and

‘Demograph-ics’ (increased 9.0%). In contrast, there was a reduced

completenessrateintheelectronicadmissionformsin

com-parison with the paper formsin the information category

of ‘General Contact’ by 14.2%. There was no statistically

significant difference between the two types of forms in

the categories of ‘End of Life Wishes’, ‘Doctor’ and ‘Legal

Contact.

Ase-Form6ande-Form7weretheautomationofForm3

andForm5,respectively,acomparisonofcompletenessrateof

theircommonitems(68and40,respectively)withineachpair

was conducted.Theresults showedthat the completeness

ratesofthetwoformatsofelectronicadmissionformswere

significantlyhigherthanthatoftheircounterparts(p<0.01)

(Fig.1).

3.3. Comprehensivenessofdocumentationinthe

paper-basedrecordsandEHRs

Variationinthecomprehensivenessratewasfoundamong

different form formats in total and for each information

category (Table 3). The overall comprehensiveness rates

for seven formats ranged from 21% for Form 5 to 41%

for e-Form 6. The difference among them was significant

(p<0.01).

A comparison of the overall comprehensiveness rate

betweenany twoofthe sevenformformats indicatedthat

17 out of21pairs offormshad statisticallysignificant

dif-ferences (p<0.05). Specific comparison between any two

of seven form formats at each information category level

showed that 145 out of 210 pairs of forms (69%) for an

informationcategoryhadstatisticallysignificantdifferences

(p<0.05).

A statistically significant increase in the overall

com-prehensiveness rate was found inthe admission formsin

the EHRs comparedwith paper-based forms (40.0% versus

28.6%, p<0.01). At the level of information category in a

form, significantincreases (p<0.01)inthe electronicforms

were found in the data categories of ‘Admission Details’,

‘Baseline HealthRanges’,‘Membership’,‘Demographic’,and

‘GeneralContact’.Therewasasignificantdecreasewith

‘Com-pletion of Form’ and ‘HealthHistory’ (p<0.01). No change

was found in the categories of ‘Doctor’ and ‘Legal

Con-tact’. The difference for the category ‘End of Life Wishes’

was not significant. Fig. 2 presents the comparison of

mean comprehensiveness rates between paper-based and

electronic admission forms in total and by information

Please cite this article in pr ess as: N. W ang, et al., Description and comparison of quality of electr onic v ersus paper -based resident admission forms in A ustr alian ag e d car e facilities, Int. J. Med. Inform. (2012), http://dx.doi.or g/10.1016/j.ijmedinf.2012.11.011

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Table3–Distributionofmediancompletenessandcomprehensivenessrates(%),andnumbersofitemsperformamongdifferentformformats.

Informationcategory Form1 Form2 Form3 Form4 Form5 e-Form6 e-Form7 Totalpaper-basedb _TotalEHRsb

Samplesize 73 18 13 15 28 223 28 147 251

Demographics

Completenessrate(IQR)a _{73(9)a 81(16)ab 70(35)a 89(22)b 89(22)cb 91(9)bd 86(18)be 82(16)A 91(9)B}

Numberofitemsintheform 11 8 10 9 9 11 11 10 11

Comprehensivenessrate(IQR) 50(6)a 44(13)b 43(22)bc 50(6)ace 50(13)bc 63(6)d 59(13)de 50(13) 63(6) Admissiondetails

Completenessrate(IQR) 75(0)acd 100(0)a 75(0)b 67(0)abcd 100(0)abd 80(0)c 83(0)d 75(0)A 80(0)B

Numberofitemsintheform 4 3 12 3 3 15 6 4. 14

Comprehensivenessrate(IQR) 25(0)a 19(6)b 56(6)c 19(6)bd 19(5)be 69(6)f 31(0)g 25(6)A 69(6)B

Healthhistory

Completenessrate(IQR) 36(14)a 50(50)b 100(8)c 33(0)d 100(38)ce 67(0)f 67(0)bfg 43(33)A 67(0)B

Numberofitemsintheform 14 2 2 6 2 3 6 8. 3

Comprehensivenessrate(IQR) 44(11)a 17(11)b 22(11)cd 22(11)bcd 22(0)bc 22(0)d 30(0)e 33(22) 22(0)

Baselinehealthranges

Completenessrate(IQR) n/a n/a n/a n/a n/a 20(40) n/a n/a 20(40)

Numberofitemsintheform n/a n/a n/a n/a n/a 5 n/a n/a 5

Comprehensivenessrate(IQR) n/a n/a n/a n/a n/a 25(50) n/a n/a 25(100)

Membership

Completenessrate(IQR) 17(0)a 50(33)b 31(12)c 33(33)cd 20(20)e 38(23)f 29(12)cg 17(17)A 38(23)B

Numberofitemsintheform 6 6 13 9 10 13 17 8 13

Comprehensivenessrate(IQR) 13(0)a 19(13)bd 25(16)ce 19(19)bc 13(13)ad 31(19)e 31(13)e 13(6)A 31(19)B Endoflifewishes

Completenessrate(IQR) 100(0)a 40(2)b 50(0)bc 67(3)bd n/a 50(5)d n/a 67(5)A 50(5)A

Numberofitemsintheform 2 5 2 3 n/a 2 n/a 2 2

Comprehensivenessrate(IQR) 4(0)a 40(20)b 20(0)c 40(20)abe n/a 20(2)e n/a 40(40)A 20(20)A

Doctor

Completenessrate(IQR) 60(4)a 13(1)b 33(2)c 75(3)ad 0(0)e 33(0.2)f 1(0)g 40(6)A 50(2)A

Numberofitemsintheform 5 16 6 4 4 6 7 6. 6

Comprehensivenessrate(IQR) 40(2)ab 40(2)ab 40(3)ac 60(4)b 40(0)c 40(2)b 1(0)d 40(20)A 40(20)B

Generalcontact

Completenessrate(IQR) 78(11)a 28(40)b 57(0.21)cf 53(29)cdf 70(38)ce 57(24)f 63(13)cfg 71(42)A 57(23)B

Numberofitemsintheform 9 10 21 17 10 21 16 11. 20.

Comprehensivenessrate(IQR) 44(6)a 36(24)ac 50(19)b 50(22)bd 22(0)c 55(22)b 44(0)d 39(22)A 50(22)B

Legalcontact

Completenessrate(IQR) n/a 0.35(0.20)a 0(0)a 0(0.3)ab 0.17(0.3)b 0(1.0)ab 0(0.3)ab 0(30)A 0(100)A

Numberofitemsintheform n/a 10 2 4 6 3 4 3 3.

Comprehensivenessrate(IQR) 0a 0(15)bc 0(0)b 8(0.15)c 8(8)c 0(23)bc 0(8)bd 0(0)A 0(0)B

Completionofform

Completenessrate(IQR) 100(0)a 100(0)ab n/a n/a 50(0)c n/a n/a 1(1) n/a

Numberofitemsintheform 1 3 n/a n/a 2 n/a n/a 1 n/a

Comprehensivenessrate(IQR) 33(33)a 1(42)b n/a n/a 33(0)c n/a n/a 33(33) n/a

Total

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission – T able 3 (Continued ) Information cate gor y F orm 1 F orm 2 F orm 3 F orm 4 F orm 5 e-F orm 6 e-F orm 7 T otal paper -based b T otal EHRs b Number of items in the form 52 63 68 55 46 79 67 54 78 Compr ehensi v eness rate (IQR) 29 (4)a 27 (9)a 33 (4)b 30 (7)a 21 (5)c 41 (7)d 33 (4)be 28 (6)A 40 (9)B Letters refer to comparisons of completeness and compr ehensi v eness rates for differ ent form formats. The same letter for v alues fr om differ ent forms indicates that ther e wa s no significant differ ence betw een them. Differ ent letters for v alues indicate ther e wa s a significant differ ence in the rates. The same appr oac h has been used in comparison of rates for the total paper based and total EHRs. a IQR: interquartile rang e . b V alues for n umber of items in the tw o totals columns ar e the means of v alues fr om the se v e n F orm columns.

3.4. Frequenciesofdocumenteditemsinadmission formsbetweenpaper-basedrecordsandEHRs

Items of the admission forms were put into seven groups

according to their frequency of documentation among

the sample forms. Sixteen data elements were frequently

recorded(frequency>70%)and44wereinfrequentlyrecorded

(frequency<30%)inbothdocumentationsystems.Somedata

elementswerefrequentlyrecordedinpaper-basedforms,but

wereseldompresentinEHRsforms,orviceversa(Table4).

3.5. Associationbetweenthenumberofitemsandthe completenessrateandcomprehensivenessrateof admissionforms

Atthelevelofeachinformationcategory,thenegative

associ-ationbetweenthecompletenessrateandthenumberofitems

designedinaformwasstatisticallysignificantforpaper-based

forms(seeTable4,correlationcoefficient−0.26,p<0.001).This

suggestsatendencythatincreasingthenumberofitemsis

associatedwithadecreasedcompletenessrate.Nosuch

ten-dencywasidentifiedinelectronicadmissionforms.

The associations between the comprehensiveness rates

andthenumberofitemsinaformwerehighlysignificantly

positiveatanoverallandeachinformationcategorylevelsin

bothpaper-basedandelectronicadmissionforms(seeTable5).

Thismaysuggest thatincreasingthe numberofitemsina

formisassociatedwithincreasedamountofdatacollected.

4.

Discussion

Thisstudyusedaqualitativeapproachtoderiveachecklist

of resident admission datathat covers all of the

informa-tionitemsinsevenadmissionformsusedinnineagedcare

facilities.Thequalityofdocumentationofpaper-basedand

electronicresidentadmissionformswasquantitatively

mea-suredandcomparedtoreflecttheextenttowhichresident

admissiondatawererecorded.Themeasurementwas

under-taken at threelevels in each form:overall, byinformation

categoryandbyindividualdataelement.Threemeasureswere

usedinthestudy:completenessrate,comprehensivenessrate

andthefrequencyproportionofdocumenteddataelement.

Additionally,theassociationsbetweenthenumberofitems

and theircompletenessand comprehensivenessrateswere

identifiedatoverallandinformationcategorylevelsforallthe

formsandbetweenpaper-basedandelectronicsystems.

Thestudyidentifiedvaryingpracticeamongthe

participat-ingagedcareorganisationsinthedocumentationofresident

backgroundinformationintheadmissionforms.Inthe

previ-ouspaper-baseddocumentationsystems,differentformatsof

admissionformswereusedacrossthethreeagedcare

organi-sations.Withineachorganisation,theformatoftheadmission

formscould alsobedifferentacross thefacilitiesorwithin

eachfacility.

InOrganisation2,Form1wasusedinFacilityEandForm

2inFacilityF,whileboththeseformswereusedinFacilities

CandD.Form1wasissuedundertheNursingFacilitiesAct

1988andwasusedforresidentsadmittedbefore2003.Form

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission formsinAustralianagedcarefacilities,Int.J.Med.Inform.(2012),http://dx.doi.org/10.1016/j.ijmedinf.2012.11.011

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Note: the bar on the top of histogram is standard error 0 10 20 30 40 50 60 70 80 90 100

Mean completeness rate (%)

Paper-based Electronic

a b

a

b

Form 3 vse-Form 6 Form 5 vse-Form 7

Fig.1–Comparisonofmeancompletenessratesofcommonitemsbetweenthepaper-basedandelectronicadmission

formsbyeachpair.Note:thebaronthetopofhistogramisstandarderror.

Thisreflectedachangeofthedocumentationpracticeinthe

organisationovertime.InOrganisation3,bothFacilitiesHand

IusedForm3,whileFacilityGusedForms1,3and4.The

rea-sonforthisisthatFacilityGwaspreviouslyunderdifferent

managementandjointedOrganisation3inthelatterstage.

Therefore,differentformatofformswasfoundinthefacility

fortheolderpeoplewhowereadmittedatdifferentstages.On

theotherhand,theimplementationoftheEHRhas

standard-isedtheformatofresidentadmissionformsinOrganisations

2and3.Thisshouldsupportcommunicationandexchange

ofinformationbetweendifferentorganisationsandfacilities

andtheuseofdataforvariouspurposes.

Wefoundthattheelectronicadmissionformshadbetter

completenessandcomprehensivenessratesthanpaper-based

forms.This evidencewas furthersupportedby a

compari-sonofcompletenessratesbetweenthecommonitemsintwo

pairsofpaper-basedandtheirelectronicderivatives.Ahigher

completenessrateintheelectronicformsmaysuggestthat

theEHRsweremoreconvenientforthenursestoenterdata

itemsthanusingthepaper-basedrecordsystems.Thisresult

isconsistentwiththepreviousfindingsthattheuseofEHRs

was conducivetomorecomplete documentationbyhealth

careprofessionals[12].Anincreasedcomprehensivenessrate

in electronicadmission formssuggests thatmore resident

admissiondatawerecontainedintheEHRs.Thisshould

facili-tatenursesandothercarestaffinconductingriskassessment

andplanningmoreappropriatecaretotheresidents.

Despite the enhancedquality ofdocumentation of

resi-dentadmissiondataintheEHRs,theoverallcompletenessand

comprehensivenessratesforbothpaper-basedandelectronic

admissionformswerenothigh.Inregardtothecompleteness

rate,onlyabout56%ofitemsinthepaper-basedformsand60%

Note: the bar on the top of histogram is standard error 0 10 20 30 40 50 60 70 80 90 100 M ea n c o m p re he ns iv en es s ra te ( % ) Information category Paper-based Electronoc b a b a b a b a b a a a a b a a b a

Fig.2–Comparisonofmeancomprehensivenessratesofadmissionformsbetweenpaper-basedrecordsandEHRsintotal

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission

Table4–Admissionformitemsandgroupsbyleveloffrequencyofdocumentation(n=251electronicversus147 paper-basedadmissionforms).

Group Items

Itemswithahighfrequencyofdocumentation (>70%)inbothpaper-basedandelectronic forms

Fullname,DOB,gender,religion,maritalstatus,countryofbirth,agedcarefacility, admissiondate,allergies,medical/surgicaldiagnosis,Medicarecardnumber,doctor name,primarycontactname,primarycontactrelationship,primarycontact address,primarycontactphone,nextofkinname,nextofkinrelationships,nextof kinaddress,nextofkinphoneno.

Itemswithalowfrequencyofdocumentation (<30%)inbothpaper-basedandelectronic forms

Residentphonenumber,secondarylanguage,interpreterneeded,working company,otherinformation,residentURnumber,medicalrecordnumber,external causeofinjuryandpoisoning,placeofoccurrenceofinjury,fluvaccination,chest X-ray,psychiatrichistory,weight,bloodsugarlevel,bloodpressure,pension/benefit carenumber,AustralianDVTcardnumber,hospitalinsurance,privatehealth insuranceprovider,privatehealthinsurance/fundnumber/table,ambulantfund, diabetesassociationnumber,electionroll,warservice,funeraldirectivephone number,advancedcaredirective,summaryofwishes,doctoraddress,doctoremail, primaryandsecondarycontactandnextofkin’semailandfax,powerofattorney’s addressandemail,guardianship’sname,address,phoneandemail,locationofwill, solicitor’snameandphonenumber,nameofnursecompletingtheform

Itemswithahighfrequencyofdocumentation (>70%)onlyinelectronicforms

Title,preferredname,primarylanguage,aboriginalorTorresStraitIslander,diet, room,location,medicationtrolley,admissionstatus,entrytype,residentcategory, funeralarrangement,doctorphone

Itemswithahighfrequencyofdocumentation (>70%)onlyinthepaper-basedforms

None Itemswithalowfrequencyofdocumentation

(<30%)onlyintheelectronicforms.

Age,residentusualaddress,admittedfrom/sourceofreferral,otherhealth conditionpresent,drugsonadmission

Itemswithalowfrequencyofdocumentation (<30%)onlyinthepaper-basedforms

Title,preferredname,diet,room,bed,location,medicationtrolley,phototaken, admissionstatus,entrytype,residentcategory,carerecipientID,height,Centrelink number,Medicarecardmembernumber,nameasitappearsonMedicarecard, Medicarecardexpirydate,transportaccessscheme,doctorfax,secondarycontact name,secondarycontactrelationship,secondarycontactaddress,secondary contactphonenumber,powerofattorneytype,powerofattorneyname,powerof attorneyphonenumber

Itemswithafrequencybetween30%and70%in bothpaper-basedandelectronicforms

Pensiontype,funeraldirector/undertaker

ofthoseintheEHRswererecorded.Theoverall comprehen-sivenessratewasalsolowforbothpaper-basedandelectronic forms(29%and40%,respectively).IntheparticipatingRACFs, aresidentadmissionformwasusuallydocumentedbya regis-terednurse(RN)orsometimesbyanendorsedenrollednurse (EEN)inthenursingstationwhentheresidentwasfirst admit-tedintothefacility.Documentationcouldalsobeconducted byanursingmanagerintheoffice.Incomplete documenta-tion can reflectthe nurses’poor documentation behaviour andimpliesthatthereliabilityandvalidityoftheinformation sourceiscompromised[5],indicatinganeedforimprovement.

Thequality ofnursing documentationisdetermined by

three characteristics: documentation structureand format,

documentation process and documentation content [21].

Lowcompletenessandcomprehensivenessratesofnursing

recordsidentifiedinthisstudyinboththepaper-basedand

electronicformscouldbecausedbythefactorsrelatedtothe

threeinterrelatedcharacteristicsofqualityofdocumentation

andneedtobeeffectivelyaddressedbyadocumentation

sys-tem.In regard tothe structuresof thetwo typesofforms

thatcoulddeterminedataentry,thepaper-basedforms

pro-vided the opportunityforanurse toenterseveraltypesof

Table5–Correlationsbetweenthenumberofitemsinaformandthecompletenessandcomprehensivenessratesofthe form.

Correlationvariables Paper-basedadmissionforms Electronicadmissionforms

Correlationcoefficient pvalue Correlationcoefficient pvalue

Totalnumberofitemsversusoverall completenessrate

−0.156 0.06 −0.024 0.704

Numberofitemsversuscompleteness rateforeachcategory

−0.260 <0.001 0.055 0.010

Totalnumberofitemsversusoverall comprehensivenessrate

0.527 <0.001 0.451 <0.001

Numberofitemsversus

comprehensivenessrateforeach category

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission formsinAustralianagedcarefacilities,Int.J.Med.Inform.(2012),http://dx.doi.org/10.1016/j.ijmedinf.2012.11.011

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data:writing free-text data,selecting answers fromseveral

pre-formattedanswerswithatickbox,orselecting‘yes’or

‘no’optiontoaquestion.Intheelectronicmedium,afree-text

fieldforanursetotypeindatawasavailableformostitems.

Forsomeitems,anursecanselectanswersfromadrop-down

listortickboxofanswers,choose‘yes’or‘no’optionsbyradio

buttons.

Intermsofdocumentationprocess,somenurses’poor

typ-ingskillandinabilitytousethesystemcompetentlymightbe

theimpedimentforthemtoenterdatainthecomputer,with

thedirectconsequenceofincompletedocumentation.Inthis

situation,providingtrainingtonursestoimprovetheirskillsin

usingelectronicsystemsshouldbehelpful.Increasingnurses’

access to the records by placing computers in convenient

locationinthewardsmayalsofacilitatethedocumentation

process.

Inrelationtothecontentofdocumentation, lackof

rel-evanceofsomedataitemstoaresident’sspecificsituation

couldbethereasonforincompletedocumentation.Defining

relevantandadequate dataitemsisessentialtoencourage

documentation.

Poorcomprehensivenessratecouldbecausedbythe

vari-ationinthenumberandtypesofdataitemsamongdifferent

formformats,whichhadresultedinincreasednumberofdata

elementsinthechecklist.Differencesintheformatsanddata

itemsinvariousadmissionformsusedindifferentagedcare

organisationsalsoraisethequestionofwhichdataitemsare

essentialforcollectingrelevantresidentdatatomeetcareand

managementpurposes.Unnecessaryitemsintheformsmight

compromisetheprivacyofresidentsandaddtonurses’

doc-umentationworkload,thusbeingcounter-productivethrough

discouragingnursingstafftodocument.

Residentadmissionformscontainedawiderangeof

infor-mationconceptsunder10categories.Itappearsthatcertain

items tended to be recorded more often than the others.

Frequentlycollecteddataitemsweremainlyunderthe

cat-egories of ‘demographic’, ‘general contact’ and ‘admission

details’forbothpaper-basedandelectronicforms.Poorly

doc-umenteddataitemsinbothpaper-basedandelectronicforms

weremainlyunderthecategoriesof‘membership’and‘legal

contact’.Thelowcompletenesscouldalsobecausedbythe

inapplicabilityofsomeitemstoaresident’ssituation,butthe

nursesneededtoatleastdocumenta‘n/a’or‘nil’inthedata

fieldstoinformthemessagereceivers thattheinformation

itemshadbeenreviewed.AsmanyolderpeopleinRACFshave

poor cognitive capacity [22], incomplete documentation of

essentialinformationaboutthemmayleadtonurses’lackof

comprehensiveunderstandingabouttheolderpeople’sneeds

andtheprovisionofsub-optimalcaretothem.

Theitemsunderthecategoryof‘baselinehealthranges’,

whichwereaddedtooneoftheEHRsbeingwidelyusedin

sevenfacilities,were poorlycompleted.Ontheother hand,

itemssuchas‘HistoryofInjury’,‘FluVaccination’,‘Chest

X-ray’,‘PsychiatricDiagnoses’werenotformattedinthisnew

EHR.Alackofthisinformationinthecurrentelectronicforms

may confine the planning of appropriate care to the

resi-dents.Thesolutionforthisproblemmayberecordingthem

inothersectionsoftheEHRssuchasassessmentforms,but

thismaycauseconfusiontonurseswhenretrievingthe

infor-mationforimmediateuse inplanning care.Redundancyof

documentation could alsobe aconcern if thesedata were

storedinothersectionsofthesystems.

Completenessrateandcomprehensivenessratemeasured

differentconceptsinthisstudy.Completenessratecanonly

indicatetheextenttowhichitemsinaformaredocumented

byanursewhendifferentformatsofformsarecompared.A

formwithahighercompletenessrate,butlessitemsmaynot

containmoreinformationthanaformwithmoreitems,but

alowercompletenessrate.Itcouldreflecttheusefulnessof

itemsinaformorthenurses’documentationbehaviour.On

theotherhand,acomprehensivenessratecantellhowmuch

informationiscollectedinaformrelativetoacommon

check-listandthereforemakesdifferentformswithvaryingnumber

ofitemscomparable.

The results ofthe correlation analysis described above

may indicate thatforcollectingthe same typeof

informa-tioninapaper-basedform,increasingthenumberofitems

couldleadtomoredatatobecaptured,thoughitmightcause

nurses’reluctancetocompletetheseitems,thusresultingin

decreasedcompletenessrateoftheforms.Incontrary,both

completenessand comprehensiveness(amountof

informa-tion)wereimproved,regardlessofthenumberofitems.These

relationships between the number of items designed in a

formandthecompletenessandcomprehensivenessratesmay

provideimplicationsforthedesignofforms.

Thestudy hasalsoidentified issueswith coding or

ter-minologies in paper-based forms. For example, in Form 1

under theinformationcategoryof“Health History’, several

itemsweredesignedtocaptureinformationaboutaresident’s

different diagnoses.Themeaningsoftheseitems couldbe

overlappedorvaguetonursesandthismightbethereasonfor

thelowcompletenessrateforthisinformationcategory(36%).

Another example is that items referring tothe same

con-ceptweregivendifferentnameindifferentformformats.For

instance,‘Doctor’wasnamedas‘Physician’,‘MedicalDoctor’,

‘GeneralPractitioner’,or‘MedicalOfficer’indifferentforms.

Application of standardised terminology would ensure the

semanticinteroperabilityofEHRsforcommunicationbetween

systems[23].

Thereareseverallimitationstothestudy.Theadmission

formswereconvenientlycollectedfromnineagedcare

facili-tiesinthreeorganisations.Astherewasarelativelyconsistent

approachtothedocumentationineachofagedcare

organi-sation,ourresultsarerepresentative ofthe documentation

practice withinthe participating facilitiesor organisations.

However, the results may not fully reflect the practice of

recordingresidentadmissiondatainotheragedcarefacilities

ororganisations.Anotherlimitationisthatthedevelopment

of thechecklist and the analysisofdata didnot take into

accountanymandatoryfieldsoftheadmissionforms.Itwas

assumedthatalloftheitemsinaformshouldbedocumented,

though someitems suchas‘AdditionalInformation’ might

notbenecessary.Therearealsoitemssuchasthose about

secondaryandlegalcontactandmembershipdetails,which

mightnotbeapplicableforeveryresident.Theseitemscould

beconsideredasnotmandatory,thusadistinctionbetween

‘notdocumented’and‘notapplicable’couldimprovethe

accu-racyofthisstudy;however,thisinformationwasdifficultto

retrievebecause it wasimpossible tohaveadirectcontact

Pleasecitethisarticleinpressas:N.Wang,etal.,Descriptionandcomparisonofqualityofelectronicversuspaper-basedresidentadmission

fornursingdocumentationintheparticipatingorganisations.

Thislackofconsiderationofthedifferencebetween

manda-toryandoptionalfields mayhaveresultedinalowranking

ofquality ofdocumentation forsomeforms.Moreover,the

studyfocusedontheoccurrenceofdocumentationand did

notconsiderwhathadbeenrecorded.Thiscouldcausebias

tothestudyresultsifinconsistentorinaccurateinformation

hadbeenrecorded.

5.

Conclusion

Varyingdocumentationpracticeexistedwithprevious

paper-basedsystemsincollectingresidentadmissioninformation.

Theimplementationoftheelectronicnursingdocumentation

systemstandardisedvariousformatsofpaper-based

admis-sionformsacrosstheagedcarefacilitiesandorganisations.

Italsocontributedtobetterqualityofdocumentationof

res-identadmissionforms,aclearbenefitofusingEHRsinthe

agedcarefacilities.However,theresidentadmissionformsin

theEHRswerestillincomplete,implyinganeedforfurther

improvementindocumentationpractice.

Thisstudyanalysedthedatacoverageofdifferent

admis-sionforms and theircompleteness both ingeneral and in

different information categories. The research finding can

informbetterdesignofelectronicforms.

Furtherstudiesareneededonwhatinformationis

essen-tialtocollectfromresidentsontheiradmission;whatfactors

leadtoincompletedocumentationinadmissionforms;what

factorscause varyingdocumentationpracticesand whatis

theimpactofpoordocumentationonthequalityofcareand

safetyofresidents.

Authors’

contributions

NingWang,PingYuandDavidHaileycontributedtothe

con-ceptionanddesignofthestudy.Datacollection,analysisand

interpretationweredonebyNingWang.NingWangprepared

thefirstdraftofthemanuscript.NingWang,PingYuandDavid

Haileycriticallyrevisedtheimportantintellectualcontentof

themanuscript.Allauthorsapprovedthefinalmanuscriptfor

submission.

Conflict

of

interest

Theauthors claimthatthereisnoconflictofinterest with

conductionofthestudy.

Acknowledgements

Thestudyisapartofabroadresearchprojectfundedbythe

AustralianResearchCouncilandfiveagedcareorganisations

inAustralia. Theauthorswouldlike tothanktheresidents

andtheirrepresentativesforgivingconsentfortheresearch

teamtocollectand analysetheirrecordsinthisstudy.The

authorswouldalsoliketoacknowledgenurses,nursing

man-agersandmanagementgroupsoftheparticipantagedcare

organisationsforgivingtheresearchteamsupportandaccess

totheagedcarefacilitiestocollectresearchdata.

Summarypoints

Whatwasknownbeforethisstudy

• Asanimportantdatasourceforadministrative pur-poses and careplanning inagedcare facilities, the qualityofresidentadmissionformshasrarelybeen investigatedbyresearchers.

• Poordocumentationofpatientadmissioninformation inanacutesettingwithpaper-basedsystemandEHRs hasbeenidentifiedbypreviousstudies.

• ImplementationofEHRshasthepotentialtoimprove thequalityofdocumentationindifferenthealth sett-ings.

Whatthisstudyaddedtoourknowledge

• Bettercompletenessandcomprehensivenessof doc-umentationwereachievedbytheEHRsusedinnine residentialagedcarefacilitiesinthisstudy.

• Documentation of resident admission forms needs furtherimprovement.

• DesignofEHRsneedstoconsiderthecontentofforms, whichisakeyforbetteraggregationofdata.

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