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Nurses` perceptions concerning patient records in Swedish nursing homes
Engelsk titel: Nurses` perceptions concerning patient records in Swedish nursing homes Läs online Författare: Ehrenberg A Språk: Eng Antal referenser: 33 Dokumenttyp: Artikel UI-nummer: 01049911

Tidskrift

Vård i Norden 2001;21(1)9-14 ISSN 0107-4083 E-ISSN 1890-4238 KIBs bestånd av denna tidskrift Denna tidskrift är expertgranskad (Peer-Reviewed)

Sammanfattning

The aim of this study is to compare nurses' perceptions concerning the documentation of nursing care in patient records in nursing homes and other comparable facilities in six Swedish municipalities. Nurses who recently received training in care-planning and recording were compared with nurses that did not receive such training. A postal questionnaire was answered by 165 (86%) of the nurses. Of these, 80 had participated in an intervention program (study group) to improve their nursing recording. The remaining 85 nurses were allocated to a reference group. In contrast to the reference group, significantly fewer nurses in the study group reported dissatisfaction with their documentation and significantly more nurses reported always documenting nursing history and nursing status. The main purpose of the patient record was described by both groups as the daily basis for care delivery and as a means of establishing the security of the patient. The nurses in the study group mentioned the record as a legal document with greater frequency than the reference group. The reference group reported spending more time on the oral reports. Conclusions from the study are that nurses have difficulties in integrating the structured approach of the nursing process and in expressing the contents of nursing care in writing.