首页   按字顺浏览 期刊浏览 卷期浏览 Nursing Documentation in Patient Records
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

 

点击下载:  PDF (495KB)



返 回