Abstract:
Nurses generate large quantities of data at different operational levels in a
health service organization. Administrative managerial data include the number
if nursing hours per patient day and cost data related to nursing services while
clinical data include the documentation if 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 difinitions, but much of the same information
can befound 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 if datasets for nursing research are explored.
