The need for standardised documents in continuity of care: results of standardising the eNursing summary.
Continuity of care is a concept that is defined as the uninterrupted and coordinated care provided to a patient and that includes an informational dimension which describes the information exchange between the parties involved. In nursing, the nursing summary is the main instrument to ensure informational continuity of care. The aim of this paper is to present an HL7 Clinical Document Architecture based document standard for the eNursing Summary and to discuss the need for harmonizing these results at international level. The eNursing Summary proposed in this paper was developed on the basis of several internationally accepted concepts, primarily the nursing process, the ISO 18104 Reference Terminology Model for Nursing and various data sets. The standardisation process embraced several phases of involving nursing experts for validating its structure and content. It was finally evaluated by a network of 100 healthcare organizations. We argue that the eNursing Summary is a good starting point for standardising nursing discharge and transfer documents on a global level. However, further work is needed to bring together the different national and international strands in standardisation. .
Hübner
Ursula
U
Health Informatics Research Group, University of Applied Sciences, Osnabrück, Germany. u.huebner@fh-osnabrueck.de
Flemming
Daniel
D
Heitmann
Kai U
KU
Oemig
Frank
F
Thun
Sylvia
S
Dickerson
Audrey
A
Veenstra
Marcia
M
D003266:Continuity of Patient Care / Q000592:standards*; D006751:Hospital Information Systems; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards; D009736:Nursing Process; D010351:Patient Discharge / Q000592:standards*; D010360:Patient Transfer / Q000592:standards*; D012015:Reference Standards