ABSTRACT Oulu University of Applied Sciences Degree Programme in Nursing and Health Care, Option of Nursing

Author: Irma Kovalainen Title of thesis: Developing of Nursing Discharge Summary in Vaala Health Center Hospital Supervisors: Pirkko Sandelin & Tuula Nissinen Spring term 2011 Number of pages: 81

My thesis was a part of a cooperation development project with Oulu University of Applied Sciences and Vaala Health Center Hospital in 2009-2010. HOIVAKE project was carried out in a nationwide eNNI project, which dealt with electronic structured documentation of nursing care in Finland. The purpose of HOIVAKE project was to standardize nursing documentation in accordance with the nursing process and to create a standardized model for documentation of nursing discharge summary in Vaala Health Center Hospital. The purpose was also to encourage the nursing staff to become familiar with the electronic structured documentation and to approach the new way of documentation gradually at their daily work. Nursing discharge summary is the first nursing document archived in the archive of electronic health records in Finland. Documentation of a nursing discharge summary requires the use of standardized terminology in different phases of the nursing process.

The method used in HOIVAKE project was embedding, an interactive learning process in education and working life to put new models or innovations into practice. The whole nursing staff, nursing student, nursing teacher and information specialist participated in the common learning process. The nursing staff received training in order to use the nursing process and the nursing discharge summary in daily work and acquainted with the electronic structured nursing documen-tation. The nursing discharge summary created in HOIVAKE project consists of the main events during the patient care episode based on the nursing process. It is documented narratively using the titles nationally defined. The titles are based in nursing core data of Finland. The nursing discharge summary outlines the patient`s care she needs in the further treatment place. It means better communication among nurses and other health care providers as well as better care for the patient. Information is in real time and continuity of care and safety of patients will improve.

The project was evaluated using a questionnaire form. The results revealed that nursing staff was satisfied with the development project. The nursing summary is useful, patient-centered and clear enough to use in nursing practice. The nursing staff needs time and further training to adopt a new model to document nursing summary in standardized way. It is important that the patient record system supports the documentation of a nursing discharge summary. Therefore the implementation of the new model and development work continues in Vaala Health Center Hospital.