title: Comparing nursing handover and documentation: forming one set of patient information.
abstract: OBJECTIVE
  The aim of this study was to explore the potential for one set of patient information for nursing handover and documentation.
  
  
  BACKGROUND
  Communication of patient information requires two processes in nursing: a verbal summary of the patients' care and another report within the nursing notes, creating duplication.
  
  
  BACKGROUND
  Advances in speech recognition technology have provided an opportunity to consider the practicality of one set of information at the nursing end-of-shift.
  
  
  METHODS
  We used content analysis to compare transcripts from 162 digitally recorded handovers and written nursing notes for similar patients within general medical-surgical wards from two metropolitan hospitals in Sydney Australia.
  
  
  RESULTS
  Using the Nursing Handover Minimum Dataset analysis framework similar content [n = 2109 (handover) n = 1902 (nursing notes)] was found within the handovers and notes at the end-of-shift (7:00 am and 2:00 pm). Analysis of the overarching categories demonstrated the emphasis within the differing data sources as: patient identification (31%), care planning or interventions (25%), clinical history (13%), and clinical status (13%) for handover, vs. care planning (47%), clinical status (24%), and outcomes or goals of care (12%) for nursing notes.
  
  
  CONCLUSIONS
  This study has demonstrated that similar patient information is presented at handover and within documentation. Major categories are consistent with international nursing minimum datasets in use.
  
  
  CONCLUSIONS
  We can use one set of patient information (within some limitations) for two purposes with system design, practice change and education. Experiments are currently being conducted trialling speech recognition within laboratory and clinical settings.
  
  
  CONCLUSIONS
  One set of patient information, verbally generated at handover delivering electronic documentation within one process, will transform international nursing policy for nursing handover and documentation.
authors.affiliation: School of Nursing & Midwifery, University of Western Sydney, Sydney, NSW, Australia; Centre for Applied Nursing Research (a joint facility of the South Western Sydney Local Health District and the University of Western Sydney), Sydney, NSW, Australia.
authors.forename: M
authors.initials: M
authors.lastname: Johnson
authors.forename: P
authors.initials: P
authors.lastname: Sanchez
authors.forename: H
authors.initials: H
authors.lastname: Suominen
authors.forename: J
authors.initials: J
authors.lastname: Basilakis
authors.forename: L
authors.initials: L
authors.lastname: Dawson
authors.forename: B
authors.initials: B
authors.lastname: Kelly
authors.forename: L
authors.initials: L
authors.lastname: Hanlen
mesh_terms: D003142:Communication; D004282:Documentation; D006801:Humans; D009737:Nursing Records; D009741:Nursing Staff, Hospital / Q000458:organization & administration*; D062209:Patient Handoff; D061214:Patient Safety
keywords: Acute Care < Nursing; Communication; Health Services Research < Research; Informatics; Information Technology < Information Technology; Nursing; Nursing Classification < Nursing; Patient Safety < Workforce Issues; Quantitative Methods < Research; Risk Management < Health Service Management