Törnkvist L, Gardulf A, Strender L E
Health-care Developer Division of Family Medicine, Novum, Huddinge, Stockholm, Sweden.
Vard Nord Utveckl Forsk. 1997 Winter;17(4):18-25. doi: 10.1177/010740839701700405.
Before a general, nursing documentation model was implemented in one health care region of the Stockholm County Council the opinions which district nurses and nurses at the primary health care centers (PHCCs) had of nursing documentation were investigated. 164 nurses (94%) at all the 22 PHCCs within the region answered a questionnaire in October, 1995. The study showed that the nurses in general were dissatisfied with their own, as well as with their colleagues, nursing documentation. The lack of a common, patient-record model for nursing documentation was considered the greatest obstacle, followed by lack of time and lack of knowledge. Most of the nurses believed that patient records which clearly included all parts of the nursing process would promote patient care. However, according to the nurses themselves, less than one-fifth of them recorded nursing history and nursing outcomes for all or most of their patients. One-third of the nurses reported that documented planned nursing interventions, about one-fourth nursing status and about half of them implemented nursing interventions for all or most of their patients. The nurses said that nursing diagnoses, goals and epicrises were rarely documented. There was no significant correlation between the nurses' ages and their opinions of nursing documentation. Nurses who had completed their education after 1985 were more positive to further education in nursing documentation and to computerised patient records, and confirmed more than others that patient records which included the entire nursing process model would promote patient care. Nurses who worked only at PHCCs were more satisfied with their own documentation as well as with that at their centres and were more positive to computer support than district nurses. Nurses at PHCCs were less in favour of education in nursing documentation, compared with nurses working in home health care and child care. The nurses who were not satisfied with their own nursing documentation were not satisfied with their colleagues' documentation either, but they were positive to further nursing education. More than others, they were of the opinion that better patient care follows from patient records which include the entire nursing process model. The study shows the need for education and continuous support aimed at nurses within the primary health care system regarding nursing documentation.
在斯德哥尔摩郡议会的一个医疗保健区域实施通用护理记录模式之前，对地区护士和初级保健中心（PHCCs）的护士关于护理记录的看法进行了调查。1995年10月，该区域内22个PHCCs的164名护士（94%）回答了一份问卷。研究表明，护士总体上对自己以及同事的护理记录不满意。缺乏通用的护理记录患者记录模式被认为是最大的障碍，其次是时间不足和知识欠缺。大多数护士认为，清晰包含护理过程所有部分的患者记录将促进患者护理。然而，据护士自己说，不到五分之一的护士为所有或大多数患者记录了护理病史和护理结果。三分之一的护士报告记录了计划的护理干预措施，约四分之一记录了护理状况，约一半的护士为所有或大多数患者实施了护理干预措施。护士们表示，护理诊断、目标和病历总结很少被记录。护士的年龄与他们对护理记录的看法之间没有显著相关性。1985年以后完成学业的护士对护理记录方面的进一步教育和计算机化患者记录更为积极，并比其他人更认同包含整个护理过程模式的患者记录将促进患者护理。仅在PHCCs工作的护士对自己的记录以及所在中心的记录更满意，并且比地区护士对计算机支持更积极。与在家居保健和儿童保健工作的护士相比，PHCCs的护士不太支持护理记录方面的教育。对自己的护理记录不满意的护士对同事的记录也不满意，但他们对进一步的护理教育持积极态度。他们比其他人更认为，包含整个护理过程模式的患者记录能带来更好的患者护理。该研究表明，有必要针对初级卫生保健系统内的护士开展关于护理记录的教育和持续支持。
