title: Standardised care plans for in hospital stroke care improve documentation of health care assessments.
abstract: OBJECTIVE
  To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record.
  
  
  BACKGROUND
  Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital.
  
  
  METHODS
  Quantitative, comparative.
  
  
  METHODS
  Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record.
  
  
  RESULTS
  Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged.
  
  
  CONCLUSIONS
  An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis.
  
  
  CONCLUSIONS
  Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.
authors.affiliation: Department of Public Health and Caring Sciences, Caring Sciences, Uppsala University, Uppsala, Sweden.
authors.forename: Ulrika
authors.initials: U
authors.lastname: Pöder
authors.affiliation: Unit for Care Development, Uppsala University Hospital, Uppsala, Sweden.
authors.forename: Marie Fogelberg
authors.initials: MF
authors.lastname: Dahm
authors.affiliation: Unit for Care Development, Uppsala University Hospital, Uppsala, Sweden.
authors.forename: Nina
authors.initials: N
authors.lastname: Karlsson
authors.affiliation: Department of Public Health and Caring Sciences, Caring Sciences, Uppsala University, Uppsala, Sweden.
authors.forename: Barbro
authors.initials: B
authors.lastname: Wadensten
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009730:Nursing Assessment / Q000592:standards*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D020521:Stroke / Q000451:nursing*; D013548:Sweden
keywords: adherence; clinical pathway; electronic health care record; multi-professional; nursing; occupational therapy; patient safety; physiotherapy; standardised care plan; stroke management