Nursing Documentation in Patient Records
作者:
Gun Nordström,
Ann Gardulf,
期刊:
Scandinavian Journal of Caring Sciences
(WILEY Available online 1996)
卷期:
Volume 10,
issue 1
页码: 27-33
ISSN:0283-9318
年代: 1996
DOI:10.1111/j.1471-6712.1996.tb00306.x
出版商: Blackwell Publishing Ltd
关键词: nursing audit;nursing documentation;quality of care
数据来源: WILEY
摘要:
The correct documentation of nursing care is a very important prerequisite for safe care. An extensive survey (n = 380 records), was conducted, using the NoGa© protocol for a review of the nurses' documentation. The documentation revealed considerable deficiencies in most of the wards, and the nursing history, status and planned interventions were inadequate in two‐thirds of the records. Furthermore, the nursing diagnosis, goals and discharge notes were especially poorly documented. The NoGa© protocol was easy to use as an audit tool, useful for screening the nurses' documentation and useful for evaluaton of the outcomes of educational programmes in nursing documentat
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