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Content of nursing discharge notes: associations with patient and transfer characteristics
Faculty of Health and Science, Nord-Trøndelag University College, Namsos, Norway.
Department of Health Sciences, Mid-Sweden University, Sundsvall, Sweden.
Department of Medicine, Division of Geriatrics, Nord-Trøndelag Health Trust, Namsos, Norway.
Faculty of Health and Science, Nord-Trøndelag University College, Namsos, Norway; Centre for Care Research Mid-Norway, Steinkjer, Norway.
2012 (English)In: Open Journal of Nursing, ISSN 2162-5336, E-ISSN 2162-5344, Vol. 2, no 3, 23179Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2012. Vol. 2, no 3, 23179
Keyword [en]
Older People; Transfer; Nursing Documentation; Hospitalization; Home Care
National Category
Nursing
Identifiers
URN: urn:nbn:se:hig:diva-25063DOI: 10.4236/ojn.2012.23042OAI: oai:DiVA.org:hig-25063DiVA: diva2:1134836
Available from: 2017-08-21 Created: 2017-08-21 Last updated: 2017-08-21Bibliographically approved

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CiteExportLink to record
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Citation style
  • apa
  • harvard-cite-them-right
  • ieee
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Language
  • sv-SE
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More languages
Output format
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