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Nursing Care as Documented in Patient Records
Author(s) -
Ehnfors Margareta,
Smedby Björn
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.tb00206.x
Subject(s) - nursing outcomes classification , nursing , nursing records , nursing documentation , documentation , audit , nursing care , medicine , nursing interventions classification , nursing care plan , primary nursing , nursing diagnosis , nursing research , nursing minimum data set , categorization , nursing process , quality (philosophy) , medline , nurse education , psychological intervention , medical diagnosis , computer science , management , economics , philosophy , artificial intelligence , law , pathology , epistemology , political science , programming language
A review of 106 nursing records from 12 wards was conducted to categorize and quantify the content of the documentation and to consider the comprehensiveness of the recording for individual nursing problems. Audit instruments, based on a model for nursing documentation were developed and applied. The results show that admission assessment was missing in slightly less than half of all records, two‐thirds had no nursing care plan and about one‐third had no documentation on nursing outcome. About 90% of the records had no nursing diagnosis, no objective or no nursing discharge note. Notes on nursing status and nursing interventions were most common. Only one‐third of the nursing problems identified had recording that gave information about the progress of the patient's problem. The analyses performed give information on the quality of nursing records which may be used to evaluate the quality of nursing care.