Mykkänen Minna, Saranto Kaija, Miettinen Merja
Kuopio university hospital, Kuopio, Finland;
NI 2012 (2012). 2012 Jun 23;2012:301. eCollection 2012.
Nursing documentation is crucial to high quality, good and safe nursing care. According to earlier studies nursing documentation varies and the nursing classifications used in electronic patient records (EPR) is not yet stable internationally nor nationally. Legislation on patient records varies between countries, but they should contain accurate, high quality information for assessing, planning and delivering care. A unified national model for documenting patient care would improve information flow, management between multidisciplinary care teams and patient safety. Nursing documentation quality, accuracy and development needs can be monitored through an auditing instrument developed for the national documentation model. The results of the auditing process in one university hospital suggest that the national nursing documentation model fulfills nurses' expectations of electronic tools, facilitating their important documentation duty. This paper discusses the importance of auditing nursing documentation and especially of giving feedback after the implementation of a new means of documentation, to monitor the progress of documentation and further improve nursing documentation.
护理记录对于高质量、优质且安全的护理至关重要。根据早期研究,护理记录存在差异,电子病历(EPR)中使用的护理分类在国际和国内都尚未稳定。各国关于患者记录的立法各不相同,但它们应包含用于评估、规划和提供护理的准确、高质量信息。一个统一的全国性患者护理记录模型将改善信息流通、多学科护理团队之间的管理以及患者安全。可以通过为全国记录模型开发的审计工具来监测护理记录的质量、准确性和发展需求。一所大学医院的审计过程结果表明,全国护理记录模型满足了护士对电子工具的期望,便于他们履行重要的记录职责。本文讨论了审计护理记录的重要性,尤其是在实施新的记录方式后给予反馈的重要性,以监测记录的进展并进一步改善护理记录。