Basic data requirements. 1. Characteristics of patient care data in the nursing home setting

Patient care data in nursing homes are limited in quantity and quality, and a data "system" is all bu nonexistent. Unique features of data in the nursing home setting are: 1) medical diagnosis is inadequate as an indicator of estimated length of stay, expected outcome, or appropriateness of placement and services; 2) there are no widely accepted classification systems to replace medical diagnosis; 3) desired outcomes in long-term care are not clearly defined or generally accepted; and 4) availability of data varies considerably by type and level of sophistication of facilities and referring agencies. Other characteristics point to the need for multidimensional data to plan multidisciplinary services and for time-related evaluations to monitor progress or decline over months and years. The "socio-psycho-somatic syndrome" that brings the patient to the nursing home must be more carefully described and used as the take-off point for assessment and planning, much as "chief complaint" is used in acute medical care. Special attention must be paid to assessment and documentation of mental function, which assumes great importance in the nursing home setting.