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Information handling in the nursing discharge note.

Ragnhild Hellesø1

  • 1Faculty of Medicine, Institute of Nursing and Health Sciences, University of Oslo, Norway. ragnhild.helleso@medisin.uio.no

Journal of Clinical Nursing
|January 5, 2006
PubMed
Summary

Hospital nurses use technical language in discharge notes, but contextualize it for clarity. Structured templates improve note completeness, aiding continuity of care across paper and electronic systems.

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Area of Science:

  • Nursing Communication
  • Health Informatics

Background:

  • Previous studies indicate communication gaps in nursing information transfer.
  • Inaccurate and irrelevant information is a concern between nurses at different organizational levels.

Purpose of the Study:

  • To describe hospital nurses' language use in nursing discharge notes for patients needing home health care.
  • To compare the completeness, structure, and content of paper versus electronic nursing discharge notes.

Main Methods:

  • Descriptive research design.
  • Text analysis framework applied to nursing discharge notes.

Main Results:

  • Nursing discharge notes are information-dense with technical terms, individualized for clarity.
  • Both paper and electronic notes show similarities and differences in information range and detail.
  • Nurses face challenges in ensuring care continuity regardless of documentation format.

Conclusions:

  • Structured, standardized templates enhance the completeness, structure, and content of nursing discharge notes.
  • Findings clarify the appropriateness of language and content in nursing discharge notes.
  • Insights are valuable for nurses planning to implement electronic patient records (EPRs).

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