Content of nursing discharge notes: Associations with patient and transfer characteristics
Affiliation(s)
Faculty of Health and Science, Nord-Tr?ndelag University College, Namsos, Norway. Department of Health Sciences, Mid-Sweden University, Sundsvall, Sweden. Department of Medicine, Division of Geriatrics, Nord-Tr?ndelag Health Trust, Namsos, Norway. Centre for Care Research Mid-Norway, Steinkjer, Norway.
Faculty of Health and Science, Nord-Tr?ndelag University College, Namsos, Norway. Department of Health Sciences, Mid-Sweden University, Sundsvall, Sweden. Department of Medicine, Division of Geriatrics, Nord-Tr?ndelag Health Trust, Namsos, Norway. Centre for Care Research Mid-Norway, Steinkjer, Norway.
ABSTRACT
Background: In situations of care transfer of older people from hospital to home care at discharge, exchanging relevant and necessary information about the patient’s health status and individual needs are of importance to ensure continuity and appropriate nursing follow-up care. Objective: The objectives of the study were to: 1) examine the content of nurses’ discharge notes of older patients’ discharged from hospital to home care, and 2) investigate the association between the content of discharge notes and characteristics of patient and transfer. Methods: The nursing discharge notes of 70 older patients admitted to a geriatric unit and a general medicine ward at a local hospital in central Norway were analysed. The discharge notes were structured in accordance with the Well-being, Integrity, Prevention, and Safety (VIPS) model. Mean, standard deviations, and independent sample t-tests were performed to show and examine differences in use of VIPS keywords in relation to patient and transfer characteristics. To examine if use of VIPS keywords could be predicted by patient and transfer characteristics, linear multiple regression analyses were used. Results: Significant differences for mean scores on used VIPS keywords in the discharge note were found for gender, age, and medical department facility. While gender and medical department facility were significant predictors of mental related keywords in the discharge note, medical department facility was a significant predictor of physical related keywords. Conclusions: The result of this study indicate that documentation of patient status in the nursing discharge note of older patients transferred from hospital to home care is incomplete and are influenced by patient and transfer characteristics. In order to ensure continuity and appropriate nursing follow-up care, we emphasize the need for a more comprehensive approach to older patients, and that this must be reflected in the nursing discharge note.
Background: In situations of care transfer of older people from hospital to home care at discharge, exchanging relevant and necessary information about the patient’s health status and individual needs are of importance to ensure continuity and appropriate nursing follow-up care. Objective: The objectives of the study were to: 1) examine the content of nurses’ discharge notes of older patients’ discharged from hospital to home care, and 2) investigate the association between the content of discharge notes and characteristics of patient and transfer. Methods: The nursing discharge notes of 70 older patients admitted to a geriatric unit and a general medicine ward at a local hospital in central Norway were analysed. The discharge notes were structured in accordance with the Well-being, Integrity, Prevention, and Safety (VIPS) model. Mean, standard deviations, and independent sample t-tests were performed to show and examine differences in use of VIPS keywords in relation to patient and transfer characteristics. To examine if use of VIPS keywords could be predicted by patient and transfer characteristics, linear multiple regression analyses were used. Results: Significant differences for mean scores on used VIPS keywords in the discharge note were found for gender, age, and medical department facility. While gender and medical department facility were significant predictors of mental related keywords in the discharge note, medical department facility was a significant predictor of physical related keywords. Conclusions: The result of this study indicate that documentation of patient status in the nursing discharge note of older patients transferred from hospital to home care is incomplete and are influenced by patient and transfer characteristics. In order to ensure continuity and appropriate nursing follow-up care, we emphasize the need for a more comprehensive approach to older patients, and that this must be reflected in the nursing discharge note.
Cite this paper
Olsen, R. , Hellzén, O. , Skotnes, L. and Enmarker, I. (2012) Content of nursing discharge notes: Associations with patient and transfer characteristics. Open Journal of Nursing, 2, 277-287. doi: 10.4236/ojn.2012.23042.
Olsen, R. , Hellzén, O. , Skotnes, L. and Enmarker, I. (2012) Content of nursing discharge notes: Associations with patient and transfer characteristics. Open Journal of Nursing, 2, 277-287. doi: 10.4236/ojn.2012.23042.
References
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[1] Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., Meinow, B. and Fratiglioni, L. (2011) Aging with multimorbidity: A systematic review of the literature. Ageing Research Reviews, 10, 430-439. doi:10.1016/j.arr.2011.03.003 [2] Nardi, R., Scanelli, G., Corrao, S., Iori, I., Mathieu, G. and Amatrian R.C. (2007) Co-morbidity does not reflect complexity in internal medicine patients. European Journal of Internal Medicine, 18, 359-368. doi:10.1016/j.ejim.2007.05.002 [3] Reed, J., Cook, G., Childs, S. and McCormack, B. (2005) A literature review to explore integrated care for older people. International Journal of Integrated Care, 5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16773170 [4] Coleman, E.A. (2003) Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51, 549-555. doi:10.1046/j.1532-5415.2003.51185.x [5] Condelius, A., Edberg, A.K., Jakobsson, U. and Hallberg, I.R. (2008) Hospital admissions among people 65+ related to multimorbidity, municipal and outpatient care. Archives of Gerontology and Geriatrics, 46, 41-55. doi:10.1016/j.archger.2007.02.005 [6] Vogeli, C., Shields, A.E., Lee, T.A., Gibson, T.B., Marder, W.D., Weiss, K.B. and Blumenthal, D. (2007) Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. Journal of General Internal Medicine, 22, 391-395. doi:10.1007/s11606-007-0322-1 [7] Gray, L.K., Smyth, K.A., Palmer, R.M., Zhu, X. and Callahan, J.M. (2002) Heterogeneity in older people: Examining physiologic failure, age, and comorbidity. Journal of the American Geriatrics Society, 50, 1955-1961. doi:10.1046/j.1532-5415.2002.50606.x [8] Chong, C.P. and Street, P.R. (2008) Pneumonia in the elderly: A review of the epidemiology, pathogenesis, microbiology, and clinical features. Southern Medical Journal, 101, 1141-1145. doi:10.1097/SMJ.0b013e318181d5b5 [9] Cerejeira, J. and Mukaetova-Ladinska, E.B. (2011) A clinical update on delirium: From early recognition to effective management. Nursing Research and Practice, 2011. doi:10.1155/2011/875196 [10] Ornstein, K., Smith, K.L., Foer, D.H., Lopez-Cantor, M.T. and Soriano, T. (2011) To the hospital and back home again: A nurse practitioner-based transitional care program for hospitalized homebound people. Journal of the American Geriatrics Society, 59, 544-551. doi:10.1111/j.1532-5415.2010.03308.x [11] Boling, P.A. (2009) Care transitions and home health care. Clinics in Geriatric Medicine, 25, 135-148. doi:10.1016/j.cger.2008.11.005 [12] Kripalani, S., Jackson, A.T., Schnipper, J.L. and Coleman, E.A. (2007) Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine, 2, 314-323. doi:10.1002/jhm.228 [13] Coleman, E.A., Min, S.J., Chomiak, A. and Kramer, A.M. (2004) Posthospital care transitions: Patterns, complications, and risk identification. Health Services Research, 39, 1449-1466. doi:10.1111/j.1475-6773.2004.00298.x [14] Garasen, H. and Johnsen, R. (2007) The quality of communication about older patients between hospital physicians and general practitioners: A panel study assessment. BMC Health Services Research, 7, 133. doi:10.1186/1472-6963-7-133 [15] Brown, E.L., Raue, P.J., Mlodzianowski, A.E., Meyers, B.S., Greenberg, R.L. and Bruce, M.L. (2006) Transition to home care: Quality of mental health, pharmacy, and medical history information. The International Journal of Psychiatry Medicine, 36, 339-349. doi:10.2190/6N5P-5CXH-L750-A8HV [16] Boockvar, K.S., Fridman, B. and Marturano, C. (2005) Ineffective communication of mental status information during care transfer of older adults. Journal of General Internal Medicine, 20, 1146-1150. doi:10.1111/j.1525-1497.2005.00262.x [17] Cwinn, M.A., Forster, A.J., Cwinn, A.A., Hebert, G., Calder, L. and Stiell, I.G. (2009) Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. Canadian Journal of Emergency Medicine, 11, 462-471. [18] Carlsson, E., Ehnfors, M., Eldh, A.C. and Ehrenberg, A. (2012) Accuracy and continuity in discharge information for patients with eating difficulties after stroke. Journal of Clinical Nursing, 21, 21-31. doi:10.1111/j.1365-2702.2010.03648.x [19] Coleman, E.A., Smith, J.D., Raha, D. and Min, S.-J. (2005) Posthospital medication discrepancies: Prevalence and contributing factors. Archives of Internal Medicine, 165, 1842-1847. doi:10.1001/archinte.165.16.1842 [20] Glintborg, B., Andersen, S.E. and Dalhoff, K. 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