How nurses view and realize documentation in primary care
2005 (English)In: Documenting nursing care. Enhancing patient care through nursing documentation:new directions for novices and experts,2005, Bern: Verlag Hans Huber , 2005, 431-437 p.Conference paper (Refereed)
The aim of this study was to describe, analyses and compare nursing documentation in primary health care in three county councils. The study was performed in Sweden during 2002-2004. 346 district nurses answered a questionnaire and 52 nursing records were audited by the audit instrument Cat-ch-Ing. The result of the survey from all three county council indicates that nurses felt that the structured form, with keywords, for the nursing record facilitated the documentation, clinical decisions and evaluation of care. The audit showed that nursing intervention and nursing status was frequently documented bur the key words nursing diagnosis and nursing goal occurred rarely. Medical facts dominated the nursing documentation and notes of the diseases effect on the individual-s daily life existed rarely. The nursing record was more a checklist for done interventions than an informative source of nursing facts.
Place, publisher, year, edition, pages
Bern: Verlag Hans Huber , 2005. 431-437 p.
IdentifiersURN: urn:nbn:se:liu:diva-42177Local ID: 61074OAI: oai:DiVA.org:liu-42177DiVA: diva2:263032
Arrangerad av Association for common European nursing diagnoses, intervention and outcomes ACENDIO2009-10-102009-10-10