Using clinical data for nursing research and management in health services.

Publication Type:
Journal Article
Contemp Nurse, 2004, 17 (1-2), pp. 8 - 18
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Nurses generate large quantities of data at different operational levels in a health service organization. Administrative managerial data include the number of nursing hours per patient day and cost data related to nursing services while clinical data include the documentation of direct patient care only. In this paper, we explain standard clinical data elements in the HIS (Hospital Information System). The construction of the data is traced from patients' medical records to coding procedures within ICD (International Classification of Disease) classification and DRG (Diagnostic Related Groups) of casemix. Examples are given from Australian data and definitions, but much of the same information can be found in hospital information systems throughout the world. Practical applications that demonstrate how patient data can be used for research and management purposes in nursing are given. Finally, future directions and issues related to the use of datasets for nursing research are explored.
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