Nursing documentation in patient records.

@article{Nordstrm1996NursingDI,
  title={Nursing documentation in patient records.},
  author={Gun Nordstr{\"o}m and Ann Gardulf},
  journal={Scandinavian journal of caring sciences},
  year={1996},
  volume={10 1},
  pages={27-33}
}
The correct documentation of nursing care is a very important prerequisite for safe care. An extensive survey (n = 380 records), was conducted, using the NoGa protocol for a review of the nurses' documentation. The documentation revealed considerable deficiencies in most of the wards, and the nursing history, status and planned interventions were inadequate in two-thirds of the records. Furthermore, the nursing diagnosis, goals and discharge notes were especially poorly documented. The NoGa… CONTINUE READING