The Research on Electronic Exchange of a Nursing Summary —The Survey of the Nursing Summary Information in Hospital Record—

Abstract

 The purpose of this study is to clarify whether the “Nursing Summary Data Items Set” can be applied to a hospital information system when nursing record is computerized and the Nursing Summary Creation System is introduced. In so doing, we have conducted a self-administered questionnaire study on 295 hospital ward managers of university hospitals and non-university hospitals as to whether the data item information are recorded, using the “Nursing Summary Data Items Set” created by the Nursing Summary Network Study Group. 171 participants with valid answers were used for the analysis among 243 respondents. As a result, it was found that 80–90% of data item information categorized into patient attributes and medical care information were recorded. On the other hand, the percentage of patient & family guidance/welfare services/home-care oriented information being recorded was approximately 40%. Moreover, as a result of separating the hospitals into university hospital group and non-university hospital group to examine their connections with the percentage of recording, significant differences were confirmed in 28 items, and showed that the percentage of recording was higher with non-university hospital group in all aspects.