Nursing service data for research in patient care

Area of Science:

• Healthcare Management
• Health Informatics
• Long-Term Care Services

Background:

• Nursing service records from Oklahoma's statewide Medicaid long-term community care program offer valuable data.
• Utilizing these records is crucial for research and improving care delivery.

Purpose of the Study:

• To describe the development of a data collection (coding) form.
• To outline a method for training lay coders to extract a minimum data set.
• To share inherent challenges encountered during the data extraction process.

Main Methods:

• Designing a specific coding form to capture a minimum data set from nursing service records.
• Implementing a training program for individuals without prior medical coding experience.
• Documenting the entire process from form development to coder training.

Main Results:

• A functional data collection form was created for the nontechnical medical care program.
• Lay coders were successfully trained to extract the minimum data set.
• Challenges and limitations in the data collection and training process were identified.

Conclusions:

• The developed data collection system and training method are effective for extracting minimum data sets from nursing records.
• This approach supports research and program improvement initiatives in long-term community care.
• Addressing inherent problems is key to successful implementation and data integrity.