title: Turning electronic health record data into meaningful information using SQL and nursing informatics.
abstract: The combination of nursing informatics knowledge with SQL code writing in an electronic health record is a powerful partnership to obtain meaningful information and improve healthcare. The purpose of this project is to use SQL and nursing informatics to identify the underpinnings and scope of present-on-patient-admission pressure ulcer documentation incongruence within the inpatient medical-surgical unit of a rural hospital. Project results reveal a 76% incidence rate of incongruent nurse and physician documentation of pressure ulcers as present on admission. However, the scope of such incongruence affects only 3% for the inpatient population. The high incidence rate of nurse-documented present-on-admission pressure ulcers without a physician diagnoses indicates a potential for lost rural hospital reimbursement and risk to patient care.
authors.affiliation: Author Affiliations: School of Nursing (Ms Moerbe) and Department of Organizational Systems and Adult Health (Dr Kelemen), School of Nursing, University of Maryland, Baltimore.
authors.forename: Miriam
authors.initials: M
authors.lastname: Moerbe
authors.forename: Arpad
authors.initials: A
authors.lastname: Kelemen
mesh_terms: D004282:Documentation / Q000379:methods / Q000706:statistics & numerical data*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D006801:Humans; D048108:Nursing Informatics / Q000379:methods*; D003668:Pressure Ulcer / Q000191:economics* / Q000451:nursing; D011381:Programming Languages; D019035:Rural Health Services