Advancing nursing documentation an intervention study using[X]patients with leg ulcer as an example
2009 (English)In: International Journal of Medical Informatics, ISSN 1386-5056, Vol. 78, no 9, 605-617 p.Article in journal (Refereed) Published
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.
Nursing records, Community health nursing, Primary health care, Medical records computerized, Wound care
Medical and Health Sciences
IdentifiersURN: urn:nbn:se:liu:diva-13021DOI: 10.1016/j.ijmedinf.2009.04.002OAI: oai:DiVA.org:liu-13021DiVA: diva2:17680