Narrative text in structured documentation of medication risks and side effects.
Electronic patient records enable the use of patient data for clinical, administrative and research purposes. However, utilising electronic data requires a structured documentation model in which standardised nursing classifications are used. Finnish Care Classification (FinCC) is based on the Clinical Care Classification. FinCC version 1.1 used in this study contains Finnish Classification of Nursing Diagnosis and Interventions. This study aims to analyse how nurses have used narrative text to complement the documentation of medication risks and side effects when the Finnish Care Classification is used. The results of this study show that content of narrative text does not always correspond with the FinCC codes used. The content of narrative text does not follow the nursing process. Especially the use of nursing diagnosis seems to be difficult. This study indicates a need for continuing education about structured documentation. Further research is needed to analyse the relationship between nursing diagnosis and interventions as well as how other components are complemented with narrative text.
Jylhä
Virpi
V
University of Kuopio, Department of Health Policy and Management Kuopio, Finland. virpi.jylha@uku.fi
Saranto
Kaija
K
D000075202:Contraindications; D004282:Documentation / Q000592:standards*; D004358:Drug Therapy / Q000451:nursing; D005387:Finland; D006801:Humans; D016347:Medical Records Systems, Computerized; D033262:Narration; D009730:Nursing Assessment / Q000592:standards*