Test of the nursing minimum data set: availability of data and reliability.

Area of Science:

• Nursing Informatics
• Health Data Management
• Clinical Data Standards

Background:

• The Nursing Minimum Data Set (NMDS) is crucial for standardizing nursing data collection.
• Assessing NMDS element availability and intercoder reliability is essential for data quality.
• Variations in clinical settings may impact data completeness and consistency.

Purpose of the Study:

• To evaluate the availability of NMDS elements in electronic health records.
• To determine the intercoder reliability of NMDS element abstraction across different healthcare settings.
• To identify specific NMDS elements that may require improved definitions or data collection procedures.

Main Methods:

• A retrospective review of 116 randomly selected patient records from four clinical settings: acute care hospital, nursing home, home health agency, and ambulatory care clinics.
• Intercoder reliability was assessed using a randomly selected subset of 23 records.
• Data analysis included calculating the availability percentage for each NMDS element and intercoder agreement using Kappa and Pearson correlation coefficients.

Main Results:

• Over 85% of NMDS elements were available for most subjects across all settings.
• The average intercoder agreement was a satisfactory 91%.
• Lower intercoder agreement was observed for specific NMDS elements, indicating potential areas for improvement.

Conclusions:

• The NMDS is largely available and reliably abstracted in diverse clinical settings.
• Refinement of definitions and data collection procedures is recommended for certain NMDS elements to enhance data consistency.
• Findings support the utility of the NMDS for quality assessment and research across the continuum of care.