Journal of Nursing & Care

Medication Documentation in Nursing Discharge Summaries at Patient Discharge from Special Care to Primary Care

Abstract

Anne Kuusisto1, Paula Asikainen and Kaija Saranto

Background: Medication reconciliation problems are common among patients at hospital discharge and can lead to adverse events. The Electronic Nursing Discharge Summary (ENDS) has the potential of reducing discharge medication errors and ensuring the safe handover of care. Aim: The aim of this study is to describe how ENDS supports medication data exchange, cooperation and work practices as well as to clarify dependencies between medication data transmission, cooperation and working practices at patient discharge from special care to primary care. Methods: This cross-sectional study is part of a larger survey which aimed at clarifying how nursing professionals in primary care experience the flow of information at patient discharge from special care to primary care or homecare. The material was collected by e-mail survey with pre-tested questionnaire in 2012 in Finland. The data was analyzed by using descriptive statistical methods. Results: A total of 180 nursing professionals answered the survey, 56 of whom reported having received ENDS. Nursing discharge summaries did not accurately and completely reflect patient medication. For instance, only 22 percent of nursing professionals were “Well” aware of the medication taken on transfer day. Less than half of the respondents felt that the medical case summary showed current patient medication "Well" (37%). There were also duplications concerning the data content of patient care in medical case summaries and in nursing summaries, especially concerning medication. We found positive dependencies between medication data transmission, cooperation and working practices. Conclusion: The results show that medication recordkeeping should be developed in ENDS at the patient transfer phase from special care to primary care.