Sjukepleiedokumentasjon i eit elektronisk samhandlingsperspektiv
2012; Volume: 7; Issue: 3 Linguagem: Inglês
10.4220/sykepleienf.2012.0133
ISSN1891-2710
AutoresAnne-Grethe Naustdal, Grete Netteland,
Tópico(s)Innovative Teaching and Learning Methods
ResumoDocumentation of health care from an electronic coordination perspectiveBackground: Nurses are required to document patient care and treatment in the electronic medical record.This documentation, combined with the use of technology, has a key role related to information transfer at entry and discharge of patients.Also in this process, nurses play an important role.When patients are relocated, however, research indicates that the quality of the documentation and information transfer is reduced; in fact, the transfer might even lead to improper medical treatment. Aim:Exploring how nurses' docu-mentation practices in hospitals and local nursing and care services challenges an electronic cooperation across administrative levels. Method:The study is designed as a case study.Data is collected through individual semi-structured interviews with nurses and nursing leaders in clinical practice in nursing home, home nursing and hospital. Result:The study shows that nursing informants often documented in chronological order based on free text, without a pre-defined structure.This challenged the nurses in the resulting production of coordination information.Knowledge and understanding of the current information needs by coordinating actors seemed to be weak.There are strong indications of untapped potential in the use of technology in the documentation process.The management of local developmental processes and the integration of ICT in current work processes seem to represent a challenge for the nursing leaders. Conclusion:The study indicates a need for stronger leadership at national and local levels of structure, content and process related to the documentation and information transfer of nurse care.
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