Nursing documentation practice on 153 hospital wards in Sweden as described by nurses

Ehnfors, Margareta, 1941- (author): Örebro universitet,Institutionen för vårdvetenskap och omsorg,Department of Social Medicine, Uppsala University, Uppsala

(creator_code:org_t)

2013-03-19
1993
English.
In: Scandinavian Journal of Caring Sciences. - Oslo, Norway : Wiley-Blackwell. - 0283-9318 .- 1471-6712. ; 7:4, s. 201-7

Related links:: https://urn.kb.se/re...; show more...; https://doi.org/10.1...; show less...

Abstract Subject headings

According to Swedish laws and regulations, registered nurses are required to document nursing care in the patient's record. In this exploratory study, nurses were asked to describe how they made their nursing records. The nursing process model was used as a framework. The findings show that a system for admission assessment was fairly common, regarding objectives and a nursing care plan together with a nursing discharge note; more than half of the wards studied recorded these aspects at least occasionally. Nursing diagnoses were seldom recorded in practice. The results reveal serious limitations and deficiencies in the practice of nursing documentation and the implementation of current laws and regulations. This underlines the importance of emphasizing nursing knowledge and nursing documentation in nursing training and practice.

About the subject

MEDICAL AND HEALTH SCIENCES: MEDICAL AND HEAL ...; and Health Sciences; and Nursing

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