Omvårdnadsdokumentation enligt VIPS modellen på sjukhem

Abstract

A review of 163 nursing documents is presented in this article. These documents were handwritten by nurses who have attended courses in nursing documentation, and who work at Swedish nursing homes. The criteria for this review were the degrees to which the records and the signatures of nurses responsible for patients have been in compliance with Swedish law. In addition whether or not nurses have documented the nursing process, and how the VIPS-model's key word system was used in documentation have both been examined. This review also encompasses how nursing diagnoses have been formulated. The result of this study shows that documentation includes the key words on level one and level two. The main key words »nursing history« and »nursing status« appeared in almost all documents. »Individual plan of nursing« appeared in two thirds of nurses' patient records. In cases where nurses have learned to formulate specific nursing diagnoses they have consistently used this method of documentation.