Comprehensiveness of EPR documentation by home care nurses.
Nursing documentation of home health care was audited in a sample of 91 electronic patient records. The audit showed that documentation by home care nurses was unstructured and incomplete in terms of the nursing process. This supports similar findings from earlier research, and prompts questions about the feasibility of the nursing process as a framework for nursing documentation in practice.
Roth Gjevjon
Edith
E
Faculty of Medicine, Institute of Nursing and Health Sciences, University of Oslo, Norway. edith.gjevjon@hig.no
Hellesø
Ragnhild
R
D004282:Documentation / Q000592:standards*; D006701:Home Nursing; D008485:Medical Audit; D016347:Medical Records Systems, Computerized; D009664:Norway