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Related Experiment Videos

Structure and content in Norwegian nursing care documentation.

T A Stokke1, M H Kalfoss

  • 1Oslo College, Department of Nursing Education, Norway. Torbjorg Aarvaag.stokke@Sv.hioslo.no

Scandinavian Journal of Caring Sciences
|September 7, 1999
PubMed
Summary

Norwegian hospitals did not fully meet nursing care documentation guidelines from 1994. The VIPS model shows potential for systematic nursing documentation, despite current gaps in records.

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Area of Science:

  • Nursing
  • Healthcare Documentation
  • Quality Improvement

Background:

  • The Norwegian Board of Health (NBH) issued recommendations for nursing care documentation in 1994.
  • Effective documentation is crucial for patient safety and continuity of care.
  • Previous assessments indicated potential deficiencies in adherence to NBH guidelines.

Purpose of the Study:

  • To evaluate nursing documentation practices in two Norwegian hospitals against NBH recommendations.
  • To assess the structure and keywords of the VIPS model for nursing documentation.
  • To identify areas for improvement in nursing care records.

Main Methods:

  • A review of 55 nursing records across 5 hospital wards.
  • Assessment of documentation completeness, including admission assessments, care plans, goals, diagnoses, interventions, progress notes, and discharge summaries.

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  • Evaluation of the VIPS model's keywords for coverage and reliability using two independent researchers.

    • Main Results:

    • All records included an admission assessment.
    • Nursing care plans were present in 62% of records; 38% lacked nursing goals.
    • 18% of records were missing diagnoses/interventions, and 45% of diagnoses lacked outcome information. Care plans were updated in only 40%, and discharge notes present in 35%.

    Conclusions:

    • NBH recommendations for nursing documentation were not met in the studied sample.
    • The VIPS model's keywords effectively covered existing documentation and demonstrated high interrater reliability.
    • The VIPS model offers a framework for achieving reliable, uniform, and systematic nursing care documentation.