Junttila K, Salantera S, Hupli M
Jorvi Hospital, Espoo, Finland.
AORN J. 2000 Nov;72(5):862-6, 868, 870-3 passim. doi: 10.1016/s0001-2092(06)62018-8.
In Finland, research studies about perioperative documentation are few, and there are no professional recommendations for perioperative documentation, such as AORN s Standards, Recommended Practices, and Guidelines. Exploring current documentation practices and contents used in Finland is the first step to establishing a standard for perioperative documentation. The need for this type of exploration resulted in a study that found that the aim of nursing documentation is not always clear, and current documentation practice does not necessarily reveal the decision making that directs patient care, demonstrate nursing resources needed, or provide data for evaluating and developing perioperative practice. Education, motivation, and computerization generally were mentioned as a means to develop documentation.
在芬兰，关于围手术期文档记录的研究很少，并且没有针对围手术期文档记录的专业建议，如美国手术室注册护士协会（AORN）的标准、推荐做法和指南。探索芬兰目前使用的文档记录做法和内容是建立围手术期文档记录标准的第一步。这种探索的必要性促成了一项研究，该研究发现护理文档记录的目的并不总是明确的，当前的文档记录做法不一定能揭示指导患者护理的决策过程、展示所需的护理资源，或为评估和发展围手术期实践提供数据。教育、激励和计算机化通常被视为发展文档记录的手段。
