A factual investigation of the information nurses transfer between facilities through nursing summary reports

Haruka Okabe, Masako Shomura, Masamichi Ogura, Daisuke Sakurai, Hideaki Matsuki, Mitsuko Nakashima
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Abstract

Objective: To clarify the medical care information nurses share among multiple facilities such as hospitals and visiting nursing stations, specialized nursing homes, and geriatric health service facilities in Japan.Methods: The research design was an exploratory survey study. We administered a questionnaire survey to registered nurses with at least three years of clinical experience from August 2020 to September 2021. Data from 257 participants were analyzed using simple tabulation, chi-square test, and univariate and multivariate analyses. Items that could not be addressed by nursing summaries alone included how to interact with patients and families, activities of daily living, and nursing procedures.Results: The results indicate that nurses require information on nursing procedures, how to interact with patients and their families, and care. Essential nursing summary report items included infectious disease, allergy, medications, final bowel movements, and tube feeding. The essential items that varied across facilities were commissioned physicians, patients’ perspectives on the disease, regular medical examinations, and peripheral symptoms.Conclusions: The summary reports were used to exchange information with other nurses, get confirmation of nursing procedures, and get confirmation of the history of the present illness. In the future, they should include customized content depending on the information requirements of each institution. These results can be used as a reference for the nursing summaries sought by recipients, leading to improved quality of care after a transition.
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通过护理总结报告对护理人员在各机构间信息传递的事实调查
目的:了解日本医院及门诊护理站、专科疗养院、老年保健服务机构等多个机构的护理信息共享情况。方法:研究设计为探索性调查研究。我们于2020年8月至2021年9月对具有三年以上临床经验的注册护士进行问卷调查。对257名参与者的数据进行简单制表、卡方检验、单变量和多变量分析。护理总结不能单独解决的项目包括如何与患者和家属互动,日常生活活动和护理程序。结果:结果显示护士对护理程序、如何与患者及其家属互动、护理等方面的信息有需求。基本护理总结报告项目包括传染病、过敏、药物、最后肠蠕动和管饲。不同设施的基本项目各不相同,包括委托医生、患者对疾病的看法、定期体检和外围症状。结论:利用总结报告与其他护士进行信息交流,确认护理程序,确认病史。在未来,他们应该包括定制的内容,根据每个机构的信息需求。这些结果可以作为接受者寻求护理总结的参考,从而提高过渡后的护理质量。
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