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Related Concept Videos

Data Collection I01:30

Data Collection I

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Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of...
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Data Reporting and Recording01:24

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Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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Nursing Assessment01:29

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The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
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[Nursing minimum data sets (NMDS) - a literature review relating to objective and data elements].

Renate Ranegger1, Elske Ammenwerth1

  • 1UMIT - Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik GmbH, Institute of Health Informatics, Hall in Tirol, Österreich.

Pflege
|November 23, 2014
PubMed
Summary

A review of Nursing Minimum Data Sets (NMDS) found six objectives and six data elements, but no clear link between them. This highlights a gap in standardizing nursing data for healthcare system analysis.

Keywords:
LiteraturanalyseMinimaler PflegedatensatzNursing Minimum Data Setliterature reviewminimum nursing care dataset

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Area of Science:

  • Healthcare Informatics
  • Nursing Science
  • Health Services Research

Background:

  • A unified nursing care database is needed to track healthcare changes.
  • Austria lacks recommendations for essential nursing data, hindering national comparisons.
  • International Nursing Minimum Data Sets (NMDS) show data comparability is feasible.

Purpose of the Study:

  • To enhance knowledge on NMDS.
  • To create a structured description of NMDS.
  • To document NMDS data elements and their objectives.

Main Methods:

  • Systematic literature review.
  • Analysis of seventy publications on NMDS.
  • Examination of eight presented NMDS.

Main Results:

  • Six central objectives identified: practice description, financial distribution, benchmarking, HR planning, trend analysis, and quality assurance.
  • Six higher-level data elements identified: operating data, demographics, diagnoses, interventions, results (quality indicators), and care intensity (clinical data).

Conclusions:

  • No clear association was found between the objectives and data elements of the studied NMDS.