Utvärdering av en omvårdnadsdokumentationsmodell

Abstract

An important part of the daily work is the nursing documentation. The purpose of this study was to describe how the nursing documentation and the informal oral report changed at a pediatric ward, when a systematic model based on the nursing process model with keyword was introduced. The nursing record and the informal oral report were studied before and after the intervention. A questionary was to be answered by the nurses after the intervention. A comparison of data showed an enhanced documentation of the nursing process. The four steps: assessment, planning, implementation and evaluation were included in all records after the intervention. The documentation of the nutrition problem-quality was improved. There were no substantial differences in the informal oral reports. The questionary showed that most of the nurses followed the steps of the nursing process and they found the nursing documentation easy to perform. This model improves the nursing documentation and is suitable at a pediatric ward.