Standardised care plans for in hospital stroke care improve documentation of health care assessments
2015 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 24, no 19-20, 2788-2796 p.Article in journal (Refereed) Published
Aims and objectives. To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record. Background. Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital. Design. Quantitative, comparative. Methods. Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record. Results. Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. Conclusions. An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. Relevance to clinical practice. Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.
Place, publisher, year, edition, pages
2015. Vol. 24, no 19-20, 2788-2796 p.
adherence, clinical pathway, electronic health care record, multi-professional, nursing, occupational therapy, patient safety, physiotherapy, standardised care plan, stroke management
Nursing Health Care Service and Management, Health Policy and Services and Health Economy
IdentifiersURN: urn:nbn:se:uu:diva-266715DOI: 10.1111/jocn.12874ISI: 000362908200010PubMedID: 26177566OAI: oai:DiVA.org:uu-266715DiVA: diva2:868583