Implementation of a structured nursing documentation in a special care unit.
The purpose of this article is to describe the piloting of nursing documentation in accordance with the national model in the Oulu University Hospital. The nursing documentation in Finland is based on the nursing process model and Nursing Minimum Data Set (NMDS). NMDS includes information on nursing diagnoses/needs; interventions, outcomes, patient care intensity and discharge summary. Nursing staff received education for documenting content which is consistent with the nursing process in the The Finnish Care Classification (FinCC). The new documentation model required time for all professional groups in the beginning. New documentation models is challenging, adequate time needs to be reserved for the staff in order to establish new documentation procedures. Successful implementation of the pilot necessitated the commitment of the nursing officers.
Kaakinen
Pirjo
P
Administration Centre, Oulu University Hospital, Oulu, Finland. pirjo.kaakinen@ppshp.fi
Torppa
Kaarina
K
D004282:Documentation / Q000592:standards*; D005387:Finland; D008499:Medical Records; D009732:Nursing Care / Q000145:classification* / Q000458:organization & administration