2009PubMedRequires access

Comprehensiveness of EPR documentation by home care nurses.

Edith Roth Gjevjon, Ragnhild Hellesø

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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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What this paper is about

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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Available 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.

Key concepts: Documentation, Nursing documentation, Audit, Nursing process, Nursing, Nursing records, Nursing care, Health care

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