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Towards basic nursing information in patient records
Örebro University, Department of Nursing and Caring Sciences. Department of Social Medicine, Uppsala University, Uppsala.
Department of Nursing Research, Karolinska Hospital; College of Health and Caring Sciences, Stockholm.
Department of Planning and Development, Falun Hospital, Falun.ORCID iD: 0000-0002-3964-196X
1991 (English)In: Vård i Norden, ISSN 0107-4083, E-ISSN 1890-4238, Vol. 11, no 3-4, p. 12-31Article, review/survey (Refereed) Published
Abstract [en]

Four key concepts for good nursing care and a list of key words for nursing documentation in patient records were established and to some extent tried in clinical practice in Sweden. The method consisted of the following steps: extensive literature review, review of nursing records, development of a list of key words on two levels, a first level corresponding to the nursing process, and a second level consisting of subdivisions for possible use in practice, use and assessment in clinical practice by nurses and students, expert panel judgement and refinement of the key words including an examination of semantic accuracy of the Swedish key words by an expert in Nordic languages. The proposed key words are presented both in English and Swedish and explanations, comments and references are given. The version of key words presented here is subject to further testing for possible modifications.

Place, publisher, year, edition, pages
1991. Vol. 11, no 3-4, p. 12-31
Keywords [en]
Nursing documentation, patient record, nursing process, nursing interventions
National Category
Medical and Health Sciences Nursing
Identifiers
URN: urn:nbn:se:oru:diva-41423PubMedID: 1842331Scopus ID: 2-s2.0-0026226647OAI: oai:DiVA.org:oru-41423DiVA, id: diva2:780449
Available from: 2015-01-14 Created: 2015-01-14 Last updated: 2020-01-28Bibliographically approved

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Ehnfors, MargaretaEhrenberg, Anna

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  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf