Many organizations have undergone substantial reorganization in the last decade. They re-engineered their business processes and exchanged proprietary, not integrated applications for more standard solutions. Integration of structured data in relational data bases has improved documentation of business transactions and increased data quality. But almost 90% of the information that organizations manage is unstructured, can not easily be integrated into a traditional database. Just like structured data, unstructured information in organizations are records, meant and used as evidence for organizational actions and transactions. Governments, courts and other stakeholders are making increasing demands for the trustworthiness of records. This is part of a long-term trend toward defining what accountability means in a digital era. An analysis of literature of information science, organization science and archival science illustrates that for accountability, reconstruction of the past is essential. Hypothesis of this paper is that for the reconstruction of the past each organization needs (at least) a combination of three mechanisms: enterprise records management, organizational memory and records auditing. Enterprise records management ensures that records meet the for accountability necessary quality requirements: integrity, authenticity, controllability and historicity. These requirements ensure records that can be trusted. Trusted records enhance the possibility of reconstructing the past. The organizational memory ensures that trusted records are preserved for as long as is necessary to comply to accountability regulations. It provides an information and communication technology infrastructure to (indefinitely) store those records and to keep them accessible. Records auditing audits enterprise records management and organizational memory to assess the possibility to reconstruct past organizational actions and transactions. These mechanisms ensure that organizations have a documented understanding of: the processing of actions and transactions within business processes; the dissemination of trusted records; the way the organization accounts for the actions and transactions within its business processes; and the reconstruction of actions and transactions from business processes over time. This understanding is important for the reconstruction of the past in digitized organizations and improve organizational accountability.
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OBJECTIVES Previous studies regarding nursing documentation focused primarily on documentation quality, for instance, in terms of the accuracy of the documentation. The combination between accuracy measurements and the quality and frequencies of outcome variables such as the length of the hospital stay were only minimally addressed. METHOD An audit of 300 randomly selected digital nursing records of patients (age of >70 years) admitted between 2013-2014 for hip surgery in two orthopaedic wards of a general Dutch hospital was conducted. RESULTS Nursing diagnoses: Impaired tissue perfusion (wound), Pressure ulcer, and Deficient fluid volume had significant influence on the length of the hospital stay. CONCLUSION Nursing process documentation can be used for outcome calculations. Nevertheless, in the first generation of electronic health records, nursing diagnoses were not documented in a standardized manner (First generation 2010-2015; the first generation of electronic records implemented in clinical practice in the Netherlands).
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Many organizations have undergone substantial reorganization in the last decade. They re-engineered their business processes and exchanged proprietary, not integrated applications for more standard solutions. Integration of structured data in relational databases has improved documentation of business transactions and increased data quality. But almost 90% of the information that organizations manage is unstructured, cannot easily be integrated into a traditional database. When used for organizational actions and transactions, structured and unstructured information are records. They are meant and used as evidence. Governments, courts and other stakeholders are making increasing demands for the trustworthiness of records. An analysis of literature of the information, organization and archival sciences illustrates that accountability needs the reconstruction of the past. Hypothesis of this paper is that for the reconstruction of the past each organization needs a combination of threemechanisms: enterprise records management, organizational memory and records auditing. Enterprise records management ensures that records meet the quality requirements needed for accountability: integrity, authenticity, controllability and historicity. They ensure records that can be trusted and enhance the possibilities for the reconstruction of the past. The organizational memory ensures that trusted records are preserved for as long as is necessary to comply with accountability regulations. It provides an ICT infrastructure to (indefinitely) store those records and to keep them accessible. Records auditing researches the first two mentioned mechanisms to assess the possibility to reconstruct past organizational actions and transactions. These mechanisms ensure that organizations have a documented understanding of [1] the processing of actions and transactions within business processes; [2] the dissemination of trusted records; [3] the way the organization accounts for the actions and transactions within its business processes; and [4] the reconstruction of actions and transactions from business processes over time. This understanding is crucial for the reconstruction of the past and for organizational accountability.
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