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Related Experiment Videos

Towards basic nursing information in patient records.

M Ehnfors, I Thorell-Ekstrand, A Ehrenberg

    Vard I Norden
    |January 1, 1991
    PubMed
    Summary
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    This study established key concepts and keywords for effective nursing documentation in Sweden. These terms aim to improve patient record quality and support the nursing process for clinicians and students.

    Area of Science:

    • Nursing
    • Health Informatics

    Background:

    • Effective nursing documentation is crucial for quality patient care.
    • Standardized terminology enhances communication and data analysis in healthcare.

    Purpose of the Study:

    • To establish key concepts for good nursing care.
    • To develop a list of keywords for nursing documentation in patient records.

    Main Methods:

    • Extensive literature review and analysis of nursing records.
    • Development of a two-level keyword system (nursing process and subdivisions).
    • Expert panel review, semantic accuracy assessment, and clinical testing in Sweden.

    Main Results:

    • Four key concepts for nursing care were identified.

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  • A comprehensive list of keywords, in both English and Swedish, was created for nursing documentation.
  • Keywords are structured to align with the nursing process and its practical application.

    • Conclusions:

    • The developed keywords provide a framework for standardized nursing documentation.
    • Further testing is recommended to refine the keywords for optimal clinical use.
    • The study contributes to improving the quality and consistency of nursing records.