Information handling in the nursing discharge note

Abstract

Aims: The aim of this paper is twofold. Firstly, it describes hospital nurses' general use of the language function in the nursing discharge notes of patients who will require posthospital home health care. Secondly, it addresses the similarities and differences in completeness, structure and content between paper and electronic nursing discharge notes.

Background: Previous research has identified gaps in the accuracy and relevance of information communicated between nurses working at different organizational levels.

Design and methods: A descriptive design with a text analysis framework was used.

Results: The study shows that the text in the nursing discharge notes is information-dense and characterized by technical terms, although the nurses contextualized and individualized the content of the terms to clarify the message. Both similarities and differences were found in range and detail of the information nurses exchanged when they used paper or electronic discharge notes.

Conclusions: The use of structured and standardized templates helped nurses improve the completeness, structure and content of the information in the nursing discharge notes.

Relevance to clinical practice: 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.