Using clinical data for nursing research and management in health services

Abstract

Nurses generate large quantities of data at different operational levels in a health service organization. Administrative managerial data include the number of nursing hours per patient day and cost data related to nursing services while clinical data include the documentation of direct patient care only. In this paper, we explain standard clinical data elements in the HIS (Hospital Information System). The construction of the data is traced from patients' medical records to coding procedures within ICD (International Classification of Disease) classification and DRG (Diagnostic Related Groups) of casemix. Examples are given from Australian data and definitions, but much of the same information can be found in hospital information systems throughout the world. Practical applications that demonstrate how patient data can be used for research and management purposes in nursing are given. Finally, future directions and issues related to the use of datasets for nursing research are explored.

5?20: a model of minimum nurse-to-patient ratios in Victoria, Australia

“…A second limitation that is linked to the summative task type instrument concerns the time taken for the nurses to record the necessary data for the system to work. Heslop et al. (2004) reported that on average nurses spend up to 60% of their work time on documentation and information management.…”

Status of costing hospital nursing work within Australian casemix activity‐based funding policy

“…Casemix funding is most commonly associated with patient care costing and the allocation of funds to health‐care providers. It has, also, many other applications in health‐care management and planning 2,3 . For example it provides for productivity enhancement through benchmarking and monitoring of resource utilization patterns for inpatient services and is a common basis for comparing relative costs, cost‐effectiveness and quality of care across hospitals.…”

“…It has, also, many other applications in health-care management and planning. 2,3 For example it provides for productivity enhancement through benchmarking and monitoring of resource utilization patterns for inpatient services and is a common basis for comparing relative costs, cost-effectiveness and quality of care across hospitals. Several studies in Australia have used administrative data within casemix to study dimensions of practice such as adverse events, 4 nurse sensitive outcomes 5 , case management 6 and workforce issues.…”

The effect of a transforming care initiative on patient outcomes in acute surgical units: a time series study

“…For a condition or disease to be coded it must be documented as Health Information professionals do not diagnose (Heslop et al . ). If an event was not documented it would not be coded.…”

“…Coded data derives its information from the medical record which is reliant on the diligent documentation of the healthcare professionals. For a condition or disease to be coded it must be documented as Health Information professionals do not diagnose (Heslop et al 2004). If an event was not documented it would not be coded.…”