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Granskning av omvårdnadsdokumentationens kvalitet vid telefonrådgivning

by Nilsson, Malin; Eriksson, Carola

Abstract (Summary)
The purpose of the study was to describe the quality of nursing documentation at telephone counselling. The study was carried out at a health care centre in Gästrikland, Sweden. With help of a viewing instrument the authors reviewed 100 patient records. The fields which were reviewed was: the reason for contact, nursing goal, nursing intervention and nursing outcome. The result indicated that nurses´ nursing documentation at telephone counselling had some lacks and that it doesn't comply with the current legislation. The result indicated that the cause of contact was documented in all 100 of the patient records. Nursing goal was only documented in one of the 100 patient records. The reason for contact was documented in most of the records and nursing intervention was clearly described in half of the records. However the follow-up of the nursing intervention was only documented in one of the 100 patient records. In most of the records the text was easy to read and easy to grasp and most of the notes were signed. Further the result shows that VIPS-keywords for problems and intervention were not used in any major extent in the nursing documentation. In conclusion result shows that parts of the nurses´ documentation at telephone counselling are in need of enhancement to secure the quality of nursing care.
Bibliographical Information:

Advisor:

School:Högskolan i Gävle

School Location:Sweden

Source Type:Master's Thesis

Keywords:

ISBN:

Date of Publication:03/31/2008

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