M Johnson1, P Sanchez, H Suominen, J Basilakis, L Dawson, B Kelly, L Hanlen. 1. School of Nursing & Midwifery, University of Western Sydney, Sydney, NSW, Australia; Centre for Applied Nursing Research (a joint facility of the South Western Sydney Local Health District and the University of Western Sydney), Sydney, NSW, Australia.
Abstract
AIM: The aim of this study was to explore the potential for one set of patient information for nursing handover and documentation. BACKGROUND: Communication of patient information requires two processes in nursing: a verbal summary of the patients' care and another report within the nursing notes, creating duplication. INTRODUCTION: Advances in speech recognition technology have provided an opportunity to consider the practicality of one set of information at the nursing end-of-shift. METHODS: We used content analysis to compare transcripts from 162 digitally recorded handovers and written nursing notes for similar patients within general medical-surgical wards from two metropolitan hospitals in Sydney Australia. FINDINGS: Using the Nursing Handover Minimum Dataset analysis framework similar content [n = 2109 (handover) n = 1902 (nursing notes)] was found within the handovers and notes at the end-of-shift (7:00 am and 2:00 pm). Analysis of the overarching categories demonstrated the emphasis within the differing data sources as: patient identification (31%), care planning or interventions (25%), clinical history (13%), and clinical status (13%) for handover, vs. care planning (47%), clinical status (24%), and outcomes or goals of care (12%) for nursing notes. DISCUSSION: This study has demonstrated that similar patient information is presented at handover and within documentation. Major categories are consistent with international nursing minimum datasets in use. CONCLUSION: We can use one set of patient information (within some limitations) for two purposes with system design, practice change and education. Experiments are currently being conducted trialling speech recognition within laboratory and clinical settings. IMPLICATIONS FOR NURSING AND HEALTH POLICY: One set of patient information, verbally generated at handover delivering electronic documentation within one process, will transform international nursing policy for nursing handover and documentation.
AIM: The aim of this study was to explore the potential for one set of patient information for nursing handover and documentation. BACKGROUND: Communication of patient information requires two processes in nursing: a verbal summary of the patients' care and another report within the nursing notes, creating duplication. INTRODUCTION: Advances in speech recognition technology have provided an opportunity to consider the practicality of one set of information at the nursing end-of-shift. METHODS: We used content analysis to compare transcripts from 162 digitally recorded handovers and written nursing notes for similar patients within general medical-surgical wards from two metropolitan hospitals in Sydney Australia. FINDINGS: Using the Nursing Handover Minimum Dataset analysis framework similar content [n = 2109 (handover) n = 1902 (nursing notes)] was found within the handovers and notes at the end-of-shift (7:00 am and 2:00 pm). Analysis of the overarching categories demonstrated the emphasis within the differing data sources as: patient identification (31%), care planning or interventions (25%), clinical history (13%), and clinical status (13%) for handover, vs. care planning (47%), clinical status (24%), and outcomes or goals of care (12%) for nursing notes. DISCUSSION: This study has demonstrated that similar patient information is presented at handover and within documentation. Major categories are consistent with international nursing minimum datasets in use. CONCLUSION: We can use one set of patient information (within some limitations) for two purposes with system design, practice change and education. Experiments are currently being conducted trialling speech recognition within laboratory and clinical settings. IMPLICATIONS FOR NURSING AND HEALTH POLICY: One set of patient information, verbally generated at handover delivering electronic documentation within one process, will transform international nursing policy for nursing handover and documentation.
Authors: Linda Dawson; Maree Johnson; Hanna Suominen; Jim Basilakis; Paula Sanchez; Dominique Estival; Barbara Kelly; Leif Hanlen Journal: J Med Syst Date: 2014-05-15 Impact factor: 4.460
Authors: Hanna Suominen; Maree Johnson; Liyuan Zhou; Paula Sanchez; Raul Sirel; Jim Basilakis; Leif Hanlen; Dominique Estival; Linda Dawson; Barbara Kelly Journal: J Am Med Inform Assoc Date: 2014-10-21 Impact factor: 4.497
Authors: Gloria Reig-Garcia; Anna Bonmatí-Tomàs; Rosa Suñer-Soler; Mari Carmen Malagón-Aguilera; Sandra Gelabert-Vilella; Cristina Bosch-Farré; Susana Mantas-Jimenez; Dolors Juvinyà-Canal Journal: BMC Health Serv Res Date: 2022-05-28 Impact factor: 2.908
Authors: Maree Johnson; Samuel Lapkin; Vanessa Long; Paula Sanchez; Hanna Suominen; Jim Basilakis; Linda Dawson Journal: BMC Med Inform Decis Mak Date: 2014-10-28 Impact factor: 2.796