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In pursuit of the common thread: Nursing content in patient records with special reference to nursing home care
Uppsala University, Medicinska vetenskapsområdet, Faculty of Medicine, Department of Public Health and Caring Sciences.
2000 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The purpose of this thesis was to study different aspects of nursing content in patient records with special reference to nursing home care. The thesis focused on the content, comprehensiveness, accuracy and auditing of records, as well as the practice and perceptions of nurses in relation to recording. A national sample of nurses was asked to complete a questionnaire. The effects on recording and nurses' practice and perceptions in nursing homes following educational intervention were studied. Accuracy was examined through record reviews and interviews with nurses and patients. A literature review of record auditing methods was performed and findings from this search were applied in the assessment of a set of records.

The results indicate that the VIPS model, as a structure for nursing recording, is widespread and shows validity across various areas in Swedish health care. After the educational intervention program, documentation in nursing home care improved significantly in the study group concerning notes on nursing history, nursing status, nursing diagnoses, interventions and discharge notes. Systematic and comprehensive assessment grounded in research-based criteria were not used in the records. Accuracy varied considerably and was significantly better for some areas in the study group. After intervention, the nurses in the study group indicated that they recorded assessments of patients with greater frequency, showed greater satisfaction with their documentation and spent less time on oral reports. Procedures in auditing patient records were found to encompass four approaches: formal structure, process comprehensiveness, knowledge based and accuracy.

In conclusion, the evidence suggests that there are serious flaws in the nursing content of nursing home records though improvements can be achieved through educational means. Presently, there are serious limitations in using the patient record as the sole source of data for care delivery, quality assessment and evaluation of care.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2000. , p. 62
Series
Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 0282-7476 ; 946
Keyword [en]
Medical sciences, nursing records, nursing process, nursing homes, nursing audit, intervention study
Keyword [sv]
MEDICIN OCH VÅRD
National Category
Medical and Health Sciences
Research subject
Medicine
Identifiers
URN: urn:nbn:se:uu:diva-495ISBN: 91-554-4783-X (print)OAI: oai:DiVA.org:uu-495DiVA, id: diva2:165982
Public defence
2000-10-06, Aulan, Sjuksköterskeutbildningen, Uppsala, 13:15
Available from: 2000-09-15 Created: 2000-09-15Bibliographically approved

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CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf