Medication documentation in nursing discharge summaries at patient´s discharge from special care to primary care

International Conference on Nursing & Emergency Medicine

December 02-04, 2013 Hampton Inn Tropicana, Las Vegas, NV, USA

Anne Kuusisto and Paula Asikainen

Scientific Tracks Abstracts: J Nurs Care

Abstract :

Effective communication among nurses during the hospital discharge process is critical to patient care. For safe further care, it is important that professionals have complete and up-to-date medication information. Medication reconciliation problems are common among patients at hospital discharge and lead to adverse events. Electronic nursing discharge summary (ENDS) is regarded as essential for documenting patient´s status when patient needs continuation of care after an episode of hospitalization. ENDS has potential to reduce discharge medication errors and to ensure the safe handover of care. The ENDS has been used since 2005 in the patient transfer phase at Satakunta Hospital District (SHD) in Finland. The aim of this study is to clarify the extent to which the receiving nurses were aware of patient's medication at discharge. This study is one part of survey which aims to clarify how primary care personnel experience the flow of information at patient discharge from special care to primary care or homecare. The material was collected with e-mail survey from primary care personnel 1.11.2012 - 27.12.2012. There were a total of 180 nurses who answered the survey. Nursing discharge summaries did not accurately and completely reflect the patient medication. For example, only 22 percent of nurses were aware of medication taken at transfer day. There were also discrepancies in medication between epicrisis and nursing summaries. Renewal of electronic health record system is in process at SHD. It serves new possibilities for medication documentation.

Biography :

Anne Kuusisto is registered Nurse and completed her M.N.Sc. in 2003 at the University of Turku and her M.S.Sc. in 2012 at the University of Tampere in Finland. She also has vocational teacher qualification. Now, she is working as project co-coordinator at the Satakunta Hospital District in Finland. The Finnish Nurses Association has granted her as the first in Finland specific competencies of nursing informatics management in December 2012.