Information handling in the nursing discharge note

Abstract

Whether paper or electronic documentation is used, the findings in this study highlight the challenges nurses encounter in ensuring continuity of care during patients' trajectory through the health system. The findings may help clarify the appropriateness of the content and language nurses use in the nursing discharge note as a communication medium. This study may also be helpful to nurses planning to use EPRs, as it illustrates some of the issues which should be clarified before this is implemented.

Hospital Information Technology Systems' Impact on Nurses and Nursing Care

“…34 Several studies reported that the use of standardized nursing language or document templates may have helped improve documentation quality. 26,32,35,39 One study found no change in documentation quality within 6 months of implementing the computerized documentation system but did notice improvements in documentation at 18 months after implementation. 36 Of the studies that found no change in documentation quality, one study investigated whether a manager influenced the quality of nursing documentation and found no association between nurse satisfaction with a nurse manager and documentation quality.…”

The invisibility of the patient’s family in nursing documentation: An integrative review

“…Personal experience as well as beliefs, attitudes and mindset are reflected in the writing. [61,62] There is an old saying "if it is not documented, it is not done". This may reflect the fact that some health care professionals are more task-oriented than patient-or family-oriented.…”

Evaluation of the national nursing model and four nursing documentation systems in Finland – Lessons learned and directions for the future

“…Fogelberg-Dahm and Wadensten [31] found that standardized care plans increased the nurses' abilities to provide consistent high-quality care for all patients, decreasing documentation time as well as redundancy in documentation. In addition, standardized care plans helped the nurses to be more thorough, improving the structure and content of discharge notes [23]. Furthermore, Kuusisto et al [32] found that nurses' experiences with electronic nursing discharge summaries were mainly positive, though the new structures required careful consideration and documentation took time.…”