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Content of nursing discharge notes: Associations with patient and transfer characteristics

机译:护理出院注意事项的内容:与患者和转移特征的关联

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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.
机译:背景:在老年人出院时将护理从医院转移到家庭护理的情况下,就患者的健康状况和个人需求交换相关且必要的信息对于确保连续性和适当的护理后续护理至关重要。目的:本研究的目的是:1)检查护士从医院到家庭护理出院的老年患者出院记录的内容,以及2)研究出院记录的内容与患者特征和转移之间的关系。方法:分析了挪威中部一家地方医院的老年科和普通内科病房的70名老年患者的护理出院记录。排放注意事项是根据幸福,正直,预防和安全(VIPS)模型构建的。进行了均值,标准差和独立样本t检验,以显示和检查VIPS关键字使用方面与患者和转移特征相关的差异。为了检查患者和转移特征是否可以预测VIPS关键字的使用,使用了线性多元回归分析。结果:发现出院笔记中使用的VIPS关键字的平均得分在性别,年龄和医疗部门设施方面存在显着差异。性别和医学部门设施是出院笔记中与心理相关的关键词的重要预测指标,而医学部门设施则是与身体相关的关键词的重要预测指标。结论:这项研究的结果表明,从医院转移到家庭护理的老年患者的护理出院记录中患者状态的记录不完整,并且受患者和转移特征的影响。为了确保连续性和适当的护理后续护理,我们强调需要对老年患者采取更全面的方法,并且这必须在护理出院记录中得到反映。

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