作者: Minna Mykkänen , Kaija Saranto , Merja Miettinen
DOI:
关键词: Nurse education 、 Audit 、 Nursing Outcomes Classification 、 Patient safety 、 Documentation 、 Nursing care 、 Nursing research 、 Nursing Audit 、 Nursing 、 Medicine
摘要: Nursing documentation is crucial to high quality, good and safe nursing care. According earlier studies varies the classifications used in electronic patient records (EPR) not yet stable internationally nor nationally. Legislation on between countries, but they should contain accurate, quality information for assessing, planning delivering A unified national model documenting care would improve flow, management multidisciplinary teams safety. accuracy development needs can be monitored through an auditing instrument developed model. The results of process one university hospital suggest that fulfills nurses' expectations tools, facilitating their important duty. This paper discusses importance especially giving feedback after implementation a new means documentation, monitor progress further documentation.