Why continuity of care needs computing--results of a quantitative document analysis

Area of Science:

• Nursing
• Healthcare Informatics
• Patient Care Coordination

Background:

• Early hospital discharges necessitate improved continuity of care.
• Current paper-based discharge summaries contribute to communication gaps, including incomplete and delayed information.
• The study addresses the adequacy of paper forms in overcoming these deficits.

Purpose of the Study:

• To evaluate if paper-based nursing discharge forms are sufficiently structured and complete to mitigate communication deficits.
• To identify the limitations of existing paper discharge forms in documenting the nursing process and patient needs.

Main Methods:

• Analysis of 32 different types of nursing discharge forms.
• Assessment of forms for structure, content, and space limitations.
• Evaluation of the completeness of documentation for the nursing process and daily living activities.

Main Results:

• All analyzed paper forms exhibited compromises between structure, content, and available space.
• No form allowed for complete documentation of the nursing process.
• A minority of forms included all activities of daily living, and most were designed without inter-sectoral terminology considerations.

Conclusions:

• Existing paper-based discharge forms are inadequate for ensuring comprehensive continuity of care.
• Shortcomings in paper forms cannot be overcome without a more dynamic and flexible instrument.
• Electronic discharge summaries are proposed as an ideal solution to address these documentation and communication deficits.