Evaluation of patient records as part of developing a nursing care classification.
The aim of the study was to evaluate the content of nursing care records and the usefulness of the instrument used for their evaluation. The evaluation involved 70 patient records from seven acute special care inpatient units. The evaluation instrument used was based on Phaneuf's Nursing Audit as further developed by Lukander. The nursing records in all the care units evaluated was very good or good. However, some deficiencies were found, for instance, regarding patient teaching and recording patients' own opinions. The method proved adequate for evaluating the content of patient records.
Karkkainen
Oili
O
Development Manager, Helsinki University Central Hospital, POB 100, Finland. oili.karkkainen@hus.fi
Eriksson
Katie
K
D003657:Decision Making; D004282:Documentation; D019317:Evidence-Based Medicine; D005387:Finland; D006266:Health Education; D006801:Humans; D008499:Medical Records; D016294:Models, Nursing; D009731:Nursing Audit; D009732:Nursing Care / Q000145:classification* / Q000592:standards; D009737:Nursing Records; D012189:Retrospective Studies