| 1. |
- Ehrenberg, Anna, 1957-, et al.
(författare)
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Nursing documentation in patient records : experience of the use of the VIPS model
- 1996
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Ingår i: Journal of Advanced Nursing. - Oxon, United Kingdom : Blackwell Publishing. - 0309-2402 .- 1365-2648. ; 24:4, s. 853-67
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Tidskriftsartikel (refereegranskat)abstract
- The VIPS model for the documentation of nursing care in patient records was scientifically developed and published in 1991, with the aim of supporting the systematic documentation of nursing care and promoting individualized care. As the model seemed to be accepted and used in many parts of Sweden, a study was conducted in order to gather further information on the validity of the model, to describe the clinical and educational experience of its use and to refine it. Experience of the use of the model was gathered from a review of the scientific papers and other reports on it, from questionnaires addressed to nurses (n = 514), from comments by key informants, and from interviews with faculty members at all the nursing schools in the country. The findings showed that an intense process of change and development was occurring regarding nursing documentation. However, there were limitations in the use of the entire nursing process, especially in the specification of patient problems and the formulation of nursing diagnoses and nursing interventions. The keywords (Swedish spelling) of the VIPS model had good content validity in different areas of nursing care. The findings also indicated the need for further elaboration and revision of some of the keywords. A revised version of the VIPS model based on these findings is presented.
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| 2. |
- Ehrenberg, Anna, 1956-, et al.
(författare)
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Patient problems, needs, and nursing diagnoses in Swedish nursing home records
- 1999
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Ingår i: Nursing diagnosis : ND : the official journal of the North American Nursing Diagnosis Association. - Hoboken, USA : Wiley-Blackwell. - 1046-7459. ; 10:2, s. 65-76
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Tidskriftsartikel (refereegranskat)abstract
- Purpose: To describe the main problems, needs, risks, and nursing diagnoses and to examine the descriptions of some common and serious patient problems in nursing home records.Methods: A retrospective audit of a stratified, random sample (N = 12O) of patient records from eight nursing homes in six Swedish municipalities.Findings: Results showed major deficiencies in nursing documentation in the patient records. Only one record contained a comprehensive description of one patient problem that corresponded to the requirements of Swedish laws and regulations. No record was found that contained a systematic and comprehensive assessment of any of the selected problems based on established criteria or the use of an assessment instrument.Conclusions: Nursing documentation in patient records does not reflect the use of systematic assessment and research-based instruments for determining patient care needs. Nurses need skills in assessment in the care of the elderly to be able to set priorities in care and deliver adequate care.
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| 3. |
- Ehrenberg, Anna, 1956-, et al.
(författare)
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Patient records in nursing homes : Effects of training on content and comprehensiveness
- 1999
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Ingår i: Scandinavian Journal of Caring Sciences. - Oslo, Norway : Scandinavian University Press. - 0283-9318 .- 1471-6712. ; 13:2, s. 72-82
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Tidskriftsartikel (refereegranskat)abstract
- The purpose of this study was to describe the effects on the contents and comprehensiveness of the nursing-care documentation in the patient records at nursing homes following an educational intervention. A review was made of records (n = 120) from nursing homes in six Swedish municipalities, allocated to a study group and a reference group. All the nursing home nurses in three municipalities received education concerning the nursing process and how to document according to the VIPS model. A retrospective audit of all nursing notes in the records from the nursing homes was made before and after the intervention. Improvements were found in the contents of the records in the study group. The number of notes on nursing history more than doubled. The occurrence of the recording of nursing diagnoses, goals and discharge notes increased. No corresponding changes were observed in the reference group. In the study group, an increase in the number of acceptable notes with contents on nursing history, status, nursing diagnosis, planned and implemented interventions, and nursing discharge notes was found. This increase was significant. The comprehensiveness in the documentation of single nursing problems was only slightly improved in the study group. No record met the requirements of the national regulations on nursing documentation or followed the nursing process thoroughly.
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