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Nursing documentation for communicating and evaluating care
Linköping University, Department of Social and Welfare Studies, Health, Activity, Care. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Social and Welfare Studies. Linköping University, Faculty of Health Sciences.
2008 (English)In: Journal of Clinical Nursing, ISSN 0962-1067 (print) 1365-2702 (online), Vol. 17, no 16, 2116-2124 p.Article in journal (Refereed) Published
Abstract [en]

Aims: To investigate the utility of electronic nursing documentation by exploring to what extent and for what purpose general practitioners use nursing documentation and to what extent and in which cases care unit managers use nursing documentation for quality development of care.

Background: As health care includes multidisciplinary activities, communication about the care given is essential. To assure delivery of good and safe care, quality development is necessary. The main tool available for communication and quality development is the patient record. In many studies, nursing documentation has been found to be inadequate for this purpose.

Design: This study had a cross-sectional descriptive design.

Methods: Data were collected by postal questionnaires, one to the general practitioners (n = 544) and one to care unit managers (n = 82) in primary health care. Data were analysed by descriptive statistical and qualitative content analysis.

Results: The general practitioners usually used the nursing record as the foremost source of information for treatment follow-up. The results, however, point out weaknesses and shortcomings in the nursing records, such as difficulties in finding important information because of a huge amount of routine notes. The care unit managers generally (74%) used the record for statistical purposes, while only half of them used it to evaluate care.

Conclusion: Nursing records need more clarity and need to be more prominent regarding specific nursing information to fulfil their purpose of transferring information and to constitute a base for quality development of care.

Relevance to clinical practice: The results of this study can provide a part of a basis upon which a multi-professional patient record could be developed and which could also function as an alarm to managers at different levels to prioritise the development of nursing documentation.

Place, publisher, year, edition, pages
2008. Vol. 17, no 16, 2116-2124 p.
Keyword [en]
communication, documentation, nurses, nursing, primary care, quality
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-13020DOI: 10.1111/j.1365-2702.2007.02149.xOAI: diva2:17679
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-05-18
In thesis
1. Carrying out Electronic Nursing Documentation: Use and Development in Primary Health Care
Open this publication in new window or tab >>Carrying out Electronic Nursing Documentation: Use and Development in Primary Health Care
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Communication of care is essential in the multidisciplinary health care system and the patient record is an important tool for communication. The electronic patient record was introduced to facilitate the documentation of care, as well as the communication and evaluation of care. District nurses met the patient independently of other caregivers at the surgery or in the patient’s home. Documentation by district nurses is assumed to contribute to the view of the patient so that safe care can be carried out in primary health care.

This thesis investigates and analyses the electronic nursing documentation in primary health care with emphasis on the content, district nurses’ experiences of documentation and how the information in the documentation was used. A further aim was to implement and evaluate the effect on standardised nursing documentation, using patients with leg ulcer as an example.

A sample of 239 district nurses, 430 general practitioners and 74 care unit managers answered questionnaires about the nursing documentation and the use of it. One hundred and nine nursing records were audited. Quantitative and qualitative methods were used for data analysis.

Documentation by district nurses lacked clear nursing status, judgment (nursing diagnosis) and nursing goals. Legal requirements were not fulfilled. Medical facts were carefully documented while relevant issues to nursing occurred only seldom. District nurses stated that they were satisfied with their documentation but were in need of education. The focus of the in-service training for documentation was technical rather than involving nursing issues.

Fifty-eight per cent of the general practitioners read the nursing documentation always or often and found it valuable. They had problems, however, finding the information because of the unclear nursing status, the lack of district nurses’ judgement and the large quantity of notes regarding routine activities in district nurses’ documentation.

The nursing documentation was used by 75 % of the care unit managers for evaluating resources and by 51 % for evaluating care. The categories ’prioritisation’, ’inadequate nursing records’, and ’lack of interest’, illustrate for what reasons the care unit mangers did not use the documentation for evaluation of care.

In order to advance district nurses documentation, a standardised nursing wound care record was designed and implemented in nine primary health care centers, with a total of 83 district nurses. Eight primary health care centers were used as a control group, including 56 district nurses. A questionnaire was sent to the district nurses and 102 nursing records were audited before and after implementation. The standardised nursing record improves the descriptions of patient’s health history and status. Nursing diagnoses were more frequently used but were of low quality. Using the standardised nursing wound care record was experienced by the district nurses as being more timeconsuming but also more informative about the patient. Furthermore the knowledge in documentation increased among the district nurses in the intervention group.

Improvement of nursing documentation is necessary in order to obtain documentation that fulfills legal requirements. The managers had a great responsibility to upgrade the documentation, which can be effected by continuing support. Documentation must be seen as a means of transferring information about the patient and of determining whether the best care has been given. A standardised documentation could increase the possibility to compare and determine the value of care. Strengthening the awareness of nursing among district nurses should involve strengthening the documentation, which ought to lead to safer care for the patient.

Place, publisher, year, edition, pages
Institutionen för samhälls- och välfärdsstudier, 2008
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1054
Communication, electronic nursing, District nurses, nursing diagnosis, documentation, questionnaire
National Category
urn:nbn:se:liu:diva-11268 (URN)978-91-7393-942-3 (ISBN)
Public defence
2008-04-11, K1, Kåkenhus, Campus Norrköping, Linköpings universitet, Norrköping, 13:00 (English)
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-03-05

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Törnvall, EvaWilhelmsson, Susan
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