<p>BAKGRUND: Omvårdnadsdokumentationen har varit lagstadgad sedan 1986. Tidigare studier visar på brister i omvårdnadsdokumentationens omfattning och att omvårdnadsprocessen inte följs. VIPS-modellen används i stor utsträckning i Sverige för att dokumentera omvårdnaden. VIPS står för Välbefinnande, Integritet, Prevention och Säkerhet. SYFTE: Syftet med denna litteraturöversikt var att få en överblick över vad och i vilken utsträckning svenska sjuksköterskor dokumenterar i omvårdnadsjournalen. METOD: En litteraturöversikt har gjorts med åtta vetenskapliga artiklar. RESULTAT: Resultatet visar att sjuksköterskor i Sverige främst dokumenterar status och åtgärder. Diagnoser, mål, resultat och epikriser förekommer betydligt mer sporadiskt. Omfattningen av dokumentationen är undermålig och fullständig dokumentation enligt omvårdnadsprocessen förekommer sällan. DISKUSSION: Sjuksköterskor behöver kontinuerlig utbildning för att förstå vikten av en väldokumenterad patientjournal som följer omvårdnadsprocessen. Nya system som NANDA och NIC skulle i framtiden kunna underlätta dokumentationen genom att ett standardiserat språk tillämpas.</p> / <p>BACKGROUND: Nursing documentation has been a legal obligation in Sweden since 1986. Many earlier studies show that the documentation lack comprehensiveness and that the nursing process is not followed. In Sweden many nurses uses the VIPS-model when documenting. VIPS is acronym for the Swedish spelling words Well-being, Integrity, Prevention and Security. PURPOSE: The purpose of this study was to examine what and to what extent nurses in Sweden document in the patient-journal. METHOD: A literature review was chosen for this study. RESULT: The result shows that nurses in Sweden document nursing status and interventions the most. There is less documentation about diagnosis, goals, outcome and discharge notes. The comprehensiveness of the patient records is poor and complete documentation occurs rarely. DISCUSSION: Nurses need education to understand the importance of having a clear structure in the patient record following the nursing process. In the future a standardized language can help the nurses to document according to the nursing process by using systems as NANDA and NIC.</p>

Thesis (doctoral)--Universität Konstanz, 2009. / Includes bibliographical references (p. [170]-176) and index.

Thesis (Ph. D. in Biomedical Informatics)--Vanderbilt University, Dec. 2009. / Title from title screen. Includes bibliographical references.

Thesis (M.A.)--Northern Kentucky University, 2009. / Made available through ProQuest. Publication number: AAT 1470022. ProQuest document ID: 1905525191. Includes bibliographical references (p. 52-54.)

Dissertation (Ph.D.)--Auburn University, 2009. / Abstract. Includes bibliographic references (p.164-184).

Thesis (M.A.)--York University, 2001. Graduate Programme in Music. / Typescript. Includes bibliographical references (leaves 115-122). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://wwwlib.umi.com/cr/yorku/fullcit?pMQ71642.

published_or_final_version / abstract / toc / Computer Science and Information Systems / Master / Master of Philosophy

The aim of this thesis was to explore dietetic notes in Swedish patient records regarding content, language and the meaning of standardization. Firstly, an audit instrument for dietetic notes in patient records, Diet-NCP-Audit, was elaborated and tested. The instrument, a 14-item scoring questionnaire based on the four steps of the Nutrition Care Process (NCP), proved to have high content validity and moderate to high inter- and intra-rater reliability. The instrument was then used in an evaluation of the content, language and structure of 147 Swedish dietetic notes. Although the nutrition intervention and some information about the evaluation were well documented, the overall result showed a need for improvement in several aspects of documentation, such as nutrition prescriptions, goals and the connection between problem-etiology-symptom. After this, 30 of the audited dietetic notes were also included in a critical linguistic study exploring how the patients and dietitians were referred to in the notes. The dietetic notes contained several linguistic devices that impersonalized and passivized both the patient and the dietitian. Thus, the grammar of the dietetic notes did not enhance or reflect the patient-centered care and the active patient-caregiver relationship that is emphasized in most health care guidelines today. Finally, a focus group study was performed. Swedish dietitians’ experiences of the standardized Nutrition Care Process (NCP) and its connected terminology (NCPT) were explored and analyzed from the perspective of Habermas’ system and lifeworld concepts. While recognizing many advantages with the NCP and NCPT, dietitians also expressed difficulties in combining the structured and standardized process and terminology with a flexible, patient-centered approach in nutrition care. In summary, I argue that strategies for the improvement of dietetic documentation are needed. I also suggest that the NCP and NCPT play an essential role in dietetic professionalization. At the same time, however, this standardization may entail the risk of a reductionist view and difficulties regarding how to balance the different ideals of health care. Thus, there is a need for discussions concerning how to use and develop the NCP and dietetic language in a way that ensures the best possible care for the patient.

There is a marked trend of using information technologies to improve healthcare. Among all the health IT, electronic health record (EHR) systems hold great promises as they modernize the paradigm and practice of care provision. However, empirical studies in the literature found mixed evidence on whether EHRs improve quality of care. I posit two explanations for the mixed evidence. First, most prior studies failed to account for system use and only focused on EHR purchase or adoption. Second, most existing EHR systems provide inadequate clinical decision support and hence, fail to reveal the full potential of digital health. In this dissertation I address two broad research questions: a) Does meaningful use of EHRs improve quality of care? and b) How do we advance clinical decision making through innovative computational techniques of healthcare analytics? To these ends, the dissertation comprises four essays. The first essay examines whether meaningful use of EHRs improve quality of care through a natural experiment. I found that meaningful use significantly improve quality of care, and this effect is greater in historically disadvantaged hospitals such as small, non-teaching, or rural hospitals. These empirical findings present salient practical and policy implications about the role of health IT. On the other hand, in the other three essays I work with real-world EHR data sets and propose healthcare analytics frameworks and methods to better utilize clinical text (Essay II), integrate clinical guidelines and EHR data for risk prediction (Essay III), and develop a principled approach for multifaceted risk profiling (Essay IV). Models, frameworks, and design principles proposed in these essays advance not only health IT research, but also more broadly contribute to business analytics, design science, and predictive modeling research.

This dissertation analyzes the practice of making indigenous maps and their circulation in Oaxaca from the late sixteenth to the early eighteenth century. Indian maps functioned as visual aids to distribute land for agriculture, ranching, subsistence farming, and mining, they served as legal titles to property, and they participated in large-scale royal projects including aqueducts and assessments of human and natural resources. Map production is examined from four distinct vantage points including social networks, materials and technology, authentication, and reproduction. In each case, maestros pintores--native master painters--collaborated with a host of individuals including Spanish officials, scribes, merchants, ranchers, farmers, town councils, caciques and lesser lords, and legal professionals to visually describe the region's geographical environment. Indigenous mapping practices fostered the development of a new epistemology that combined European and Mesoamerican worldviews to negotiate the allocation of natural resources among the region's Spanish, Amerindian, and mixed-race communities. This work stresses the role of Indian painters in the formation of early modern empires highlighting the way mapmakers challenged Spanish ideals of visual representation instead re-envisioning spatial relations according to local and regional concerns.