ArticleJAMIA open2022
Do nurses document all discussions of patient problems and nursing interventions in the electronic health record? A pilot study in home healthcare.
Article in JAMIA open, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 13 papers.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
13 citing papers in PubMed.
- Delirium superimposed on dementia in post-acute care: Nurse documentation of symptoms and interventions.Geriatric nursing (New York, N.Y.)Trial
- For the record: a narrative review of ambient voice technology in clinical documentation for dentistry and wider healthcare.British dental journal · 2026Review
- Developing a Multimodal Screening Algorithm for Mild Cognitive Impairment and Early Dementia in Home Health Care: Protocol for a Cross-Sectional Case-Control Study Using Speech Analysis, Large Language Models, and Electronic Health Records.JMIR research protocols · 2026Article
- An AI-Enabled Nursing Future With no Documentation Burden: A Vision for a New Reality.Journal of advanced nursing · 2026Article
- From Conversation to Standardized Terminology: An LLM-RAG Approach for Automated Health Problem Identification in Home Healthcare.Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing · 2025Article
- Beyond human ears: navigating the uncharted risks of AI scribes in clinical practice.NPJ digital medicine · 2025Article
- Beyond electronic health record data: leveraging natural language processing and machine learning to uncover cognitive insights from patient-nurse verbal communications.Journal of the American Medical Informatics Association : JAMIA · 2025Article
- Does synthetic data augmentation improve the performances of machine learning classifiers for identifying health problems in patient-nurse verbal communications in home healthcare settings?Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing · 2025Article
- Do goals of care documentation reflect the conversation?: Evaluating conversation-documentation accuracy.Journal of the American Geriatrics Society · 2024Article
- Utilizing patient-nurse verbal communication in building risk identification models: the missing critical data stream in home healthcare.Journal of the American Medical Informatics Association : JAMIA · 2024Article
- Uncovering hidden trends: identifying time trajectories in risk factors documented in clinical notes and predicting hospitalizations and emergency department visits during home health care.Journal of the American Medical Informatics Association : JAMIA · 2023Article
- Is the patient speaking or the nurse? Automatic speaker type identification in patient-nurse audio recordings.Journal of the American Medical Informatics Association : JAMIA · 2023Article
- Is Auto-generated Transcript of Patient-Nurse Communication Ready to Use for Identifying the Risk for Hospitalizations or Emergency Department Visits in Home Health Care? A Natural Language Processing Pilot Study.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2022Article
Corrections and comments
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Authors and funding
8 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
Objective: To assess the overlap of information between electronic health record (EHR) and patient-nurse verbal communication in home healthcare (HHC). Methods: Patient-nurse verbal communications during home visits were recorded between February 16, 2021 and September 2, 2021 with patients being served in an organization located in the Northeast United States. Twenty-two audio recordings for 15 patients were transcribed. To compare overlap of information, manual annotations of problems and interventions were made on transcriptions as well as information from EHR including structured data and clinical notes corresponding to HHC visits. Results: About 30% (1534/5118) of utterances (ie, spoken language preceding/following silence or a change of speaker) were identified as including problems or interventions. A total of 216 problems and 492 interventions were identified through verbal communication among all the patients in the study. Approximately 50.5% of the problems and 20.8% of the interventions discussed during the verbal communication were not documented in the EHR. Preliminary results showed that statistical differences between racial groups were observed in a comparison of problems and interventions. Discussion: This study was the first to investigate the extent that problems and interventions were mentioned in patient-nurse verbal communication during HHC visits and whether this information was documented in EHR. Our analysis identified gaps in information overlap and possible racial disparities. Conclusion: Our results highlight the value of analyzing communications between HHC patients and nurses. Future studies should explore ways to capture information in verbal communication using automated speech recognition.
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