Adopting the national structure of nursing documentation is consequential in the development of care.
When healthcare units adopt the national structure of electronic nursing documentation, the process requires managerial support in nursing development as well as theoretical education arranged prior to the implementation. According to the experiences of the pilot units in the Central Finland Health Care District, nursing core data documentation in accordance with the national structure promotes care planning, clarifies and constructs documentation and furthermore unifies the documentation system. The change process gives rise to juridical aspects of documentation as well as a critical evaluation of the documentation contents. The early period of implementing the new theoretical aspect and proceeding from paper-based to electronic documentation required learning, training and agreement on common policy. In health care practice, there is at present one collective structure and model for nursing documentation based on national guidelines. A documented nursing plan is available when a patient is transferred between units or even into extended care. The structured care plan is also helpful when new nurses are introduced to praxis. The continuity of care is at stake when employees are transferred between units to meet the demands of resource allocation.
Ala-Hiiro
Tapio
T
MediKes Information Management, Central Finland Health Care District, Finland. tapio.alahiiro@medikes.fi
Lemmetty
Kaisa
K
Pitkänen
Satu
S
Häyrinen
Eija
E
D004282:Documentation / Q000639:trends*; D005387:Finland; D009313:National Health Programs / Q000639:trends*; D009732:Nursing Care / Q000458:organization & administration*; D048108:Nursing Informatics / Q000639:trends*