title: Standardized Nursing Documentation Supports Evidence-Based Nursing Management.
abstract: Nursing documentation is crucial to high quality, effective and safe nursing care. According to earlier studies nursing documentation practices vary and nursing classifications used in electronic patient records (EPR) are not yet standardized internationally nor nationally. A unified national model for documenting patient care improves information flow in nursing practice, management, research and development toward evidence-based nursing care. Nursing documentation quality, accuracy and development requires follow-up and evaluation. An audit instrument is used in the Kuopio University Hospital (KUH) when evaluating nursing documentation. The results of the auditing process suggest that the national nursing documentation model fulfills nurses' expectations of electronic tools, facilitating their important documentation duty. This paper discusses the importance of using information about nursing documentation and how we can take advantage of structural information in evidence-based nursing management.
authors.affiliation: Kuopio University Hospital, Kuopio, Finland.
authors.forename: Minna
authors.initials: M
authors.lastname: Mykkänen
authors.affiliation: Kuopio University Hospital, Kuopio, Finland.
authors.forename: Merja
authors.initials: M
authors.lastname: Miettinen
authors.affiliation: University of Eastern Finland, Kuopio, Finland.
authors.forename: Kaija
authors.initials: K
authors.lastname: Saranto
mesh_terms: D001291:Attitude of Health Personnel; D057286:Electronic Health Records / Q000592:standards*; D019317:Evidence-Based Medicine / Q000592:standards*; D005387:Finland; D019983:Guideline Adherence; D009737:Nursing Records / Q000592:standards*; D017410:Practice Guidelines as Topic; D057184:Practice Patterns, Nurses' / Q000592:standards*