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Patient records in nursing homes: Effects of training on content and comprehensiveness
Department of Social Medicine, Uppsala University, Uppsala; Falun College of Health and Caring Sciences, Falun.ORCID iD: 0000-0002-3964-196X
Örebro University, Department of Nursing and Caring Sciences.
1999 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 13, no 2, p. 72-82Article in journal (Refereed) Published
Abstract [en]

The purpose of this study was to describe the effects on the contents and comprehensiveness of the nursing-care documentation in the patient records at nursing homes following an educational intervention. A review was made of records (n = 120) from nursing homes in six Swedish municipalities, allocated to a study group and a reference group. All the nursing home nurses in three municipalities received education concerning the nursing process and how to document according to the VIPS model. A retrospective audit of all nursing notes in the records from the nursing homes was made before and after the intervention. Improvements were found in the contents of the records in the study group. The number of notes on nursing history more than doubled. The occurrence of the recording of nursing diagnoses, goals and discharge notes increased. No corresponding changes were observed in the reference group. In the study group, an increase in the number of acceptable notes with contents on nursing history, status, nursing diagnosis, planned and implemented interventions, and nursing discharge notes was found. This increase was significant. The comprehensiveness in the documentation of single nursing problems was only slightly improved in the study group. No record met the requirements of the national regulations on nursing documentation or followed the nursing process thoroughly.

Place, publisher, year, edition, pages
Oslo, Norway: Scandinavian University Press , 1999. Vol. 13, no 2, p. 72-82
Keywords [en]
Nursing documentation, nursing process, record audit
National Category
Medical and Health Sciences Nursing
Identifiers
URN: urn:nbn:se:oru:diva-41415DOI: 10.1080/02839319950162606ISI: 000081076500003PubMedID: 10633736Scopus ID: 2-s2.0-0033007017OAI: oai:DiVA.org:oru-41415DiVA, id: diva2:780440
Available from: 2015-01-14 Created: 2015-01-14 Last updated: 2017-12-05Bibliographically approved

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Ehrenberg, AnnaEhnfors, Margareta

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CiteExportLink to record
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