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Nursing documentation practice on 153 hospital wards in Sweden as described by nurses
Örebro University, Department of Nursing and Caring Sciences. Department of Social Medicine, Uppsala University, Uppsala.
1993 (English)In: Scandinavian Journal of Caring Sciences, ISSN 0283-9318, E-ISSN 1471-6712, Vol. 7, no 4, p. 201-7Article in journal (Refereed) Published
Abstract [en]

According to Swedish laws and regulations, registered nurses are required to document nursing care in the patient's record. In this exploratory study, nurses were asked to describe how they made their nursing records. The nursing process model was used as a framework. The findings show that a system for admission assessment was fairly common, regarding objectives and a nursing care plan together with a nursing discharge note; more than half of the wards studied recorded these aspects at least occasionally. Nursing diagnoses were seldom recorded in practice. The results reveal serious limitations and deficiencies in the practice of nursing documentation and the implementation of current laws and regulations. This underlines the importance of emphasizing nursing knowledge and nursing documentation in nursing training and practice.

Place, publisher, year, edition, pages
Oslo, Norway: Wiley-Blackwell, 1993. Vol. 7, no 4, p. 201-7
Keywords [en]
Nursing documentation, nursing practice, records, nursing process
National Category
Medical and Health Sciences Nursing
Identifiers
URN: urn:nbn:se:oru:diva-41422DOI: 10.1111/j.1471-6712.1993.tb00204.xPubMedID: 8108624Scopus ID: 2-s2.0-0027765137OAI: oai:DiVA.org:oru-41422DiVA, id: diva2:780447
Available from: 2015-01-14 Created: 2015-01-14 Last updated: 2017-12-05Bibliographically approved

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Ehnfors, Margareta

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