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Advancing nursing documentation an intervention study using[X]patients with leg ulcer as an example
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.
Linköping University, Department of Social and Welfare Studies. Linköping University, Faculty of Health Sciences.
2009 (English)In: International Journal of Medical Informatics, ISSN 1386-5056, E-ISSN 1872-8243, Vol. 78, no 9, 605-617 p.Article in journal (Refereed) Published
Abstract [en]

Aim: The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses experiences of documentation. Method: This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n = 102 and n = 92, respectively] were carried out and 126 district nurses answered questionnaires pre-intervention and 83 post-intervention. Result: The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses opinions. Furthermore, the district nurses self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses experiences of documentation in general between the two groups. Conclusion: Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.

Place, publisher, year, edition, pages
2009. Vol. 78, no 9, 605-617 p.
Keyword [en]
Nursing records, Community health nursing, Primary health care, Medical records computerized, Wound care
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-13021DOI: 10.1016/j.ijmedinf.2009.04.002OAI: oai:DiVA.org:liu-13021DiVA: diva2:17680
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2017-12-13
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
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1054
Keyword
Communication, electronic nursing, District nurses, nursing diagnosis, documentation, questionnaire
National Category
Nursing
Identifiers
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)
Opponent
Available from: 2008-03-14 Created: 2008-03-14 Last updated: 2009-03-05

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Törnvall, EvaWahren, Lis KarinWilhelmsson, Susan

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