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Evaluation of patient records as part of developing a nursing care classification
Author(s) -
Karkkainen Oili,
Eriksson Katie
Publication year - 2003
Publication title -
journal of clinical nursing
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.94
H-Index - 102
eISSN - 1365-2702
pISSN - 0962-1067
DOI - 10.1046/j.1365-2702.2003.00727.x
Subject(s) - nursing records , audit , nursing , medicine , nursing care , nursing outcomes classification , patient care , nursing minimum data set , acute care , medical record , medline , primary nursing , nurse education , health care , management , political science , law , economics , economic growth , radiology
Summary • The aim of the study was to evaluate the content of nursing care records and the usefulness of the instrument used for their evaluation. • The evaluation involved 70 patient records from seven acute special care inpatient units. • The evaluation instrument used was based on Phaneuf's Nursing Audit as further developed by Lukander. • The nursing records in all the care units evaluated was very good or good. However, some deficiencies were found, for instance, regarding patient teaching and recording patients' own opinions. • The method proved adequate for evaluating the content of patient records.