Structures for recording patient care data – Nursing discharge summary

Authors

• Minna Mykkänen nuorempi tutkija, Sosiaali-jaterveysjohtamisen laitos, Itä-Suomen yliopisto, ylihoitaja, Pohjois-Savon sairaanhoitopiiri, Kuopion yliopistollinen sairaala
• Merja Miettinen
• Kaija Saranto

DOI: https://doi.org/10.23996/fjhw.68899

Keywords:

nursing discharge summary, nursing records, electronic health records, patient data repository

Abstract

The aim of this study was to evaluate how the data structure of a national nursing discharge summary and the contents of nursing records of a transferring patient were followed within nursing discharge summaries. In this study, we described the overlapping data structures of nursing discharge summaries that had been compiled by both nurses and doctors. In addition, we described what other data structures were used. The data (N=87) were collected from the electronic patient record system in electronic format from nine inpatient wards of the research organization. The data were analyzed by calculating the frequencies and percentages of the use of data structures. The link between the different headings of the data was tested with the chi-square test and the odds rations were calculated to describe the strength of association between headings. According to the results, although the national data structure of the nursing discharge summary was used well, its use was not systematic within the same summary, and regional content titles were only partially used. Overlapping data structures were used in both nursing discharge summaries and medical summaries. Non-structured designs, which do not belong to the national structure, were also used. Therefore, health care electronic data structures must be further developed to ensure uniform completion per the determined data structure. In addition, health care professionals must be thoroughly trained to use the determined data structures; patients require uniform summaries that contain clear and usable information to support their own treatment.