Introduction: To ensure continuity of care, it is important to effectively communicate the health status of older patients who are transferred between health care organizations. The objectives of this study were to: (1) evaluate the prevalence of nursing transfer documents, and (2) identify patient and transfer characteristics associated with the presence of nursing transfer documents for older patients transferred from home care to hospital and back to home care again after hospitalization.

Methods: Nursing documents were reviewed from a total of 102 records of older inpatients admitted from home care to medical wards at a local hospital in central Norway and later discharged home. Frequencies were used to describe patient and transfer characteristics, and the prevalence of transfer documents. Pearson's chi-square test and logistic regression were used to identify possible associations between patient and transfer characteristics and the presence of nursing transfer documents.

Results: While nursing admission notes were present in 1% of the patient transfers from home care to the hospital, 69% of patient discharges from the hospital to home care were accompanied by nursing discharge notes. Patient and transfer characteristics associated with the presence of a nursing discharge note were age, gender, medical department facility, and length of hospital stay.

Conclusions: The low prevalence of nursing transfer documents constitutes a challenge to the continuity of care for hospitalized home care patients. Patient and transfer characteristics may impact the nurses' propensity to exchange patient information. These findings emphasize the need for nurses and managers to improve the exchange of written information. While nurses must strive to transfer accurate patient information at the right place and at the right time, the managers must facilitate this by providing appropriate guidelines and standards, as well as adequate personnel and resources.