For the study, researchers examined the electronic health records of 58 heart failure patients who sought care at the same academic health center over eight years. The health records included physician discharge summaries for each patient. Researchers developed nursing plans of care based on information contained in the discharge reports. The team ran this information through a computer algorithm to identify key biomedical terms and link these terms to synonyms or related terms.
The algorithm revealed overlapping terms between nurses and physicians in just 26 percent of patient records. Just four terms used by both nurses and physicians were associated with the same concept. On average, nurses used about 18 terms and physicians about 27 terms.
“Patients who are hospitalized need hands-on nursing care, in addition to the treatments ordered by a physician,” said Karen Dunn Lopez, PhD, assistant professor in the University of Illinois at Chicago College of Nursing. “This is the first evidence of its kind that illustrates how the scope of nursing practice runs parallel to, but independent of, ‘doctor’s orders.’ … I hope this study is viewed as a first step in identifying how the combination of nursing care and medical care work together to improve patient outcomes.”
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