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Nursing Documentation Practice on 153 Hospital Wards in Sweden as Described by Nurses
Author(s) -
Ehnfors Margareta
Publication year - 1993
Publication title -
scandinavian journal of caring sciences
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.678
H-Index - 66
eISSN - 1471-6712
pISSN - 0283-9318
DOI - 10.1111/j.1471-6712.1993.tb00204.x
Subject(s) - nursing , documentation , nursing documentation , nursing outcomes classification , nursing process , medicine , nursing practice , nursing care , nursing care plan , nursing records , nursing research , team nursing , exploratory research , primary nursing , nurse education , medline , sociology , computer science , political science , anthropology , law , programming language
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.