Dokumentation of Patient Problems and Nursing Diagnoses in a Sample of Swedish Nursing Records

Abstract

The documentation and comprehensiveness of the recording of individual patient problems in 140 records from seven hospital wards was reviewed. The aims was to explore what patient problems nurses describe in patient records and whether these could be represented by the keywords of nursing status in the VIPS-model and by the NANDA diagnoses respectively, was also reviewed. Two instruments based on the VIPS-model and developed in earlier studies were used; the VIPS-Review Instrument and the CNRP-instrument. Validity and reliability are discussed. Observer-agreement tests were calculated as Cohens kappa values with good result for both instruments. The result showed that the 410 patient problems or nursing diagnoses recorded were expressed mainly on a general level, they could be categorized under the keywords of nursing status in the VIPS-model and in the NANDA diagnoses. For slightly more than half of the problems there was information in the records on the solution of the problem or on the outcome of nursing care.