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Interprofessional Structured Data: Supporting the Primary and Secondary Use of Patient Documentation

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Nursing Informatics

Part of the book series: Health Informatics ((HI))

Abstract

This chapter describes milestones in the development of electronic health record systems, aiming to highlight the possibilities of interdisciplinary records to advance nursing care. Nursing data is a central element in the electronic documentation of patient care, and the use structures and terminologies facilitate safe and secure information processing and knowledge sharing. Along with patients’ diminishing length of stay, continuity of care needs tools to guarantee care coordination and information sharing between care givers. Only high-quality data can be reused for secondary purposes such as administration, statistics, and research to benefit planning, estimate costs, as well as predict and guide care processes. Nursing care is more often delivered in digital environments where professionals and patients act together.

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Author information

Authors and Affiliations

  1. Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland

    Kaija Saranto & Ulla-Mari Kinnunen

  2. Oulu University Hospital, Oulu, Finland

    Pia Liljamo

  3. Kuopio University Hospital, Kuopio, Finland

    Minna Mykkänen

  4. Satakunta Hospital District, Pori, Finland

    Anne Kuusisto & Eija Kivekäs

Authors
  1. Kaija Saranto
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  2. Ulla-Mari Kinnunen
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  3. Pia Liljamo
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  4. Minna Mykkänen
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  5. Anne Kuusisto
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  6. Eija Kivekäs
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Corresponding author

Correspondence to Kaija Saranto .

Editor information

Editors and Affiliations

  1. University of Applied Sciences (UAS) Osnabrück, Osnabrück, Niedersachsen, Germany

    Ursula H. Hübner

  2. The University of Texas at Arlington (UTA), Arlington, TX, USA

    Gabriela Mustata Wilson

  3. Healthcare Information and Management Systems Society (HIMSS), Chicago, IL, USA

    Toria Shaw Morawski

  4. The University of Texas at Arlington (UTA), Arlington, TX, USA

    Marion J. Ball

Appendix: Answers to Review Questions

Appendix: Answers to Review Questions

  1. 1.

    What opportunities do interdisciplinary documentation have?

    1. (a)

      Standardized EHR structure

    2. (b)

      Agreed headings

    3. (c)

      Improved information flow

    Explanation: Interdisciplinary documentation is based on a standardized structure, which has agreed headings used in the EHR. When the multidisciplinary team is committed to use a structured EHR, information flow will improve between the team members.

  2. 2.

    Why must nursing terminologies be evidence-based?

    1. (a)

      In order to show evidence-based patient care

    2. (b)

      In order to develop terminologies based on evidence-based practices

    3. (c)

      So that the end users can refer to evidence-based research

    Explanation: Terminologies in use must be evidence-based, and by using terminologies in nursing care documentation, we can make nursing visible and evidence the best possible patient care.

  3. 3.

    FinCC is an acronym of?

    1. (a)

      Final Clinical Cooperation

    2. (b)

      Finnish Care Classification

    3. (c)

      Finnish Clinical Classification

    Explanation: FinCC is an acronym of Finnish Care Classification.

  4. 4.

    Electronic Nursing Discharge Summary includes:

    1. (a)

      Nursing diagnosis

    2. (b)

      Nursing interventions

    3. (c)

      Nursing outcomes

    4. (d)

      Nursing intensity

    Explanation: ENDS is a compact summary of the Nursing Minimum Data Set of the care period, i.e., a summary of nursing diagnoses, nursing interventions, nursing intensity, and nursing outcomes.

  5. 5.

    What does secondary use of data mean?

    1. (a)

      Clinical data is used a second time.

    2. (b)

      Clinical data is copied to another location in the her.

    3. (c)

      Clinical data is used for a purpose other than that for which it was originally stored.

    Explanation: Secondary use of health care data means that data generated in health care activities are used for a purpose other than that for which they were originally stored. The primary patient data in EHR is filtered and combined in different ways for secondary use purposes like operational planning and information management and health care development and innovation. Patient data can be utilized in research, statistics and teaching, and regulatory guidance and control.

  6. 6.

    How does the digitalization of health care affect interprofessional collaboration or interdisciplinary documentation?

    1. (a)

      Because of digitalization, no interprofessional collaboration is needed in the future.

    2. (b)

      Only health professionals will continue to collaborate.

    3. (c)

      The role of the patient is strengthened, and patients participate, becoming increasingly involved in and responsible for data sharing.

    4. (d)

      Digitalization does not change anything.

    Explanation: The development of different kinds of digital services for citizens and health care professionals has enabled service and treatment chains to merge in new ways in different specialized fields in both primary and specialized medical care service networks. Digital health care services allow better cooperation among those working in health care service organizations. Patients will be able to view and produce their own health information as new digital tools and transactional portals are developed. Information systems and electronic identification enable secure patient participation.

  7. 7.

    What kind of services digitalization (digital transformation) allow?

    1. (a)

      Better cooperation among professionals in social welfare and healthcare service organizations.

    2. (b)

      Patient can store information on his well-being using different applications.

    3. (c)

      Digital services give instruments to improve patient-centered care.

    4. (d)

      Digital services have enabled service and treatment chains to merge in new in different fields in medical care service networks.

    Explanation: Digital services have increased customer satisfaction and the impact of services offered to patients or customers while continually gathering data for service development. Digital services allow better cooperation between those working in social welfare and healthcare service organizations. In addition, patient can store information on his wellbeing using different applications. These services have enabled service and treatment chains to merge in new ways in different specialized fields in both primary and specialized medical care service networks.

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Saranto, K., Kinnunen, UM., Liljamo, P., Mykkänen, M., Kuusisto, A., Kivekäs, E. (2022). Interprofessional Structured Data: Supporting the Primary and Secondary Use of Patient Documentation. In: Hübner, U.H., Mustata Wilson, G., Morawski, T.S., Ball, M.J. (eds) Nursing Informatics . Health Informatics. Springer, Cham. https://doi.org/10.1007/978-3-030-91237-6_14

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  • DOI: https://doi.org/10.1007/978-3-030-91237-6_14

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  • Online ISBN: 978-3-030-91237-6

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