The chaos in primary nursing data: good information reduces risk

Abstract

Nursing as a discipline has been concerned with patient data since the early days of Nightingale. Nursing data as a first source is the most effective way to obtain a true picture of the nursing services the patient obtained while visiting a healthcare facility. The objective of this paper is to provide real examples from the operational level in how nurses are handling the daily challenges in collecting data on paper forms and electronic medium, such as computational solutions. An investigation / audit of nursing forms was conducted to gain insight into the type of data elements nurses collect in medical, surgical and aged care units for admission and discharge using a progressive method of auditing documentation done by nurses. Results: nurses were familiar with the discord between collecting real patient data/information, the data required for reporting purposes for administration and / or to meet external requirements. A key finding suggested the quality and richness of data elements that describe patient’s condition are usually kept as informal documentation. Another complexity has been the use of “shell forms” which are an official template for specific documentation such as care plans. The lack of patient data and extensive misuse of these documents is an issue and adds to the existing clinical complexity. The effectiveness in documentation by reduction in duplication and increasing the quality of data is often overlooked in a grand scale. In the information era in health, the transformation from paper to electronic is demanding and the cultural reengineering is not to be underestimated. The challenge is to reduce the risk to patient, staff and organisation in the process and from the cumbersome paper format develop an information model ready for a computerised space.