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Nursing care as documented in patient records
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
1993 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 7, no 4, 209-20 p.Article in journal (Refereed) Published
Abstract [en]

A review of 106 nursing records from 12 wards was conducted to categorize and quantify the content of the documentation and to consider the comprehensiveness of the recording for individual nursing problems. Audit instruments, based on a model for nursing documentation were developed and applied. The results show that admission assessment was missing in slightly less than half of all records, two-thirds had no nursing care plan and about one-third had no documentation on nursing outcome. About 90% of the records had no nursing diagnosis, no objective or no nursing discharge note. Notes on nursing status and nursing interventions were most common. Only one-third of the nursing problems identified had recording that gave information about the progress of the patient's problem. The analyses performed give information on the quality of nursing records which may be used to evaluate the quality of nursing care.

Place, publisher, year, edition, pages
1993. Vol. 7, no 4, 209-20 p.
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
URN: urn:nbn:se:uu:diva-257200PubMedID: 8108625OAI: oai:DiVA.org:uu-257200DiVA: diva2:838821
Available from: 2015-07-01 Created: 2015-07-01 Last updated: 2015-07-13

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