Comprehensiveness of EPR documentation by home care nurses.
Edith Roth Gjevjon, Ragnhild Hellesø
Abstract
Edith Roth Gjevjon, Ragnhild Hellesø
Abstract
Nursing documentation of home health care was audited in a sample of 91 electronic patient records. The audit showed that documentation by home care nurses was unstructured and incomplete in terms of the nursing process. This supports similar findings from earlier research, and prompts questions about the feasibility of the nursing process as a framework for nursing documentation in practice.
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Nursing documentation of home health care was audited in a sample of 91 electronic patient records. The audit showed that documentation by home care nurses was unstructured and incomplete in terms of the nursing process. This supports similar findings from earlier research, and prompts questions about the feasibility of the nursing process as a framework for nursing documentation in practice.
Key concepts: Documentation, Nursing documentation, Audit, Nursing process, Nursing, Nursing records, Nursing care, Health care