The dissertation is about nursing documentation in the Intensive Care Unit (ICU) and resuscitation units of Ústřední Vojenská Nemocnice (ÚVN). The paper describes the development of the nursing process and all required documentation used when completing this task. From a theoretical perspective the paper deals with the content and application of all nursing documentation in terms of the relevant legislation. From the practical perspective the research was completed utilizing a questionnaire approach. The questionnaire was delivered at ÚVN in Prague. The research focus is about getting the information about documentation, how information is interpreted between departments as well as the incidence or impact of incorrect documentation. One of the goals of the research was to determine the satisfaction of staff regarding nursing documentation. The research concluded that clear education regarding nursing documentation requirements is required when the nurse first is exposed to the area. Furthermore the research describes that nurses are well informed about the required documentation during the orientation process. It also demonstrates that nurses are kept informed regarding legislation changes as well as the consequences of incorrect documentation. Key words: nursing process, nursing documentation

Background: In situations of care transfer of older people from hospital to home care at discharge, exchanging relevant and necessary information about the patient’s health status and individual needs are of importance to ensure continuity and appropriate nursing follow-up care. Objective: The objectives of the study were to: 1) examine the content of nurses’ discharge notes of older patients’ discharged from hospital to home care, and 2) investigate the association between the content of discharge notes and characteristics of patient and transfer. Methods: The nursing discharge notes of 70 older patients admitted to a geriatric unit and a general medicine ward at a local hospital in central Norway were analysed. The discharge notes were structured in accordance with the Well-being, Integrity, Prevention, and Safety (VIPS) model. Mean, standard deviations, and independent sample t-tests were performed to show and examine differences in use of VIPS keywords in relation to patient and transfer characteristics. To examine if use of VIPS keywords could be predicted by patient and transfer characteristics, linear multiple regression analyses were used. Results: Significant differences for mean scores on used VIPS keywords in the discharge note were found for gender, age, and medical department facility. While gender and medical department facility were significant predictors of mental related keywords in the discharge note, medical department facility was a significant predictor of physical related keywords. Conclusions: The result of this study indicate that documentation of patient status in the nursing discharge note of older patients transferred from hospital to home care is incomplete and are influenced by patient and transfer characteristics. In order to ensure continuity and appropriate nursing follow-up care, we emphasize the need for a more comprehensive approach to older patients, and that this must be reflected in the nursing discharge note.

Enligt Patientdatalagen (SFS 2008:355), 3 kap, 1 § har fastställts att sjuksköterskan är skyldig att föra journal. I varje patientjournal ska upprättas en omvårdnadsplan vilken ska vara utformad enligt omvårdnadsprocessens fem faser: bedömning, diagnos, mål, planering, genomförande och utvärdering. Omvårdnadsdokumentationen har som syfte att beskriva den vård som patienten erhållit genom att den beskriver vilka beslut som tagits, vilka åtgärder som gjorts samt vilka resultat som uppnåtts. Patienter som genomgår allogen stamcellstransplantation (SCT) upplever ofta en hög psykologisk påfrestning och själva transplantationstillfället är i sig komplext med många behandlingsrelaterade biverkningar som påverkar hela den transplanterades tillvaro både fysiskt och psykiskt. Syftet med uppsatsen var att undersöka sjuksköterskans  omvårdnadsdokumentation avseende omvårdnadsprocessen gällande patienters emotionella hälsa (EH) från utskrivningsdatum för SCT och ett år framåt. Totalt granskades 40 patientjournaler på en hematologmottagning, vilket är en mottagning som har ansvar för uppföljning och eftervård av de patienter som genomgått allogen SCT. Av dessa 40 patienter hade 73% minst en journalanteckning dokumenterad av en sjuksköterska som handlade om EH. 81% av det som var dokumenterat handlade om negativa upplevelser. Ingen patient hade upprättad omvårdnadsplan byggd enligt omvårdnadsprocessen gällande sin EH och patientens EH beskrevs i 86% under sökordet välbefinnande. Utifrån dessa resultat är författarens upplevelse att sjuksköterskorna på den här mottagningen i stor utsträckning dokumenterar patienters EH någonstans i omvårdnadsjournalen men att det saknas en planering av patientens EH som följer omvårdnadsprocessen i dess helhet. Med utgångspunkt av detta anser författaren till uppsatsen att alla sjuksköterskor borde ges möjlighet till kontinuerlig utbildning i omvårdnadsdokumentation för att upprätthålla och bättra på sin kunskap. / According to the Patient Act (SFS 2008:355), Chapter 3, § 1 has been determined that the nurse is required to keep records. Each health record shall contain a care plan which will be designed according to nursing process, five phases: assessment, diagnosis, goals, planning, implementation and evaluation. Nursing documentation is intended to describe the given care, what decisions and actions that have been taken and the results achieved. Patients undergoing allogeneic stem cell transplantation (SCT) often experience a high psychological distress and the time of transplantation is in itself complex, with many treatment- related side effects, both physically and mentally. The aim of the study was to investigate the nurse´s nursing documentation on nursing process to patient emotional health (EH) from the discharge date for SCT and one year ahead. 40 patient records were reviewed at a haematological reception, which is the reception which has responsibility for monitoring and follow-up care of patients undergoing allogeneic SCT. 73% of these 40 patients had at least one entry recorded in the journal about EH. 81% of documented records is about negative experiences. No patient had an established care plan, built according to nursing process known their EH and EH patients were described in 86% over the keyword welfare. Based on these results the author´s experience that the nurses at this clinic extensively documenting patients´ EH somewhere in the nursing journal, but that there is no planning of patient EH arising nursing process as a whole. Based on the result in the study, the author´s view is that all nurses should be given the opportunity to get training in nursing documentation in order to maintain and improve their knowledge.

Modern lifestyle (technology, increasing intensity of sport activities, motor sports) results into increasing number of injuries and traumas and their seriousness. Injuries are at the first place in the assessment of cause of death among children and adults. Traumatology deals with prevention, diagnosis and treatment of injuries involving soft tissues, bones and joints. Traumatology should be considered as a complex diagnostic-therapeutic process, which includes medical history, clinical examination and imaging methods. Based on this examination, the diagnosis is made. Then comes therapeutical considerations and possibly a patient is indicated for surgery. Evaluation scales in nursing are elementary and integral part of nursing documentation. With their help, it is possible to define the object of observation and the way of evaluation (scoring of selected manifestations). Based on the received information it is then possible to precisely identify, objectify and document the problems arising in connection with nursing care. The result is finding an adequate solution to the problem and improving the quality of nursing care. Therefore, nurses should be equipped with basic skills on how to use the scales and how to work with them. The thesis is divided into two parts, a theoretical and an empirical one. The theoretical parts contains information about traumatology, its history and trauma centers in the Czech republic. It also contains information about nursing documentation, which includes assessment scales. We mainly focused on individual assessment scales for evaluation of state of consciousness, the risk of bedsores, the risk of falling and scales for evaluation of the degree of self-sufficiency. Among other scales we dealt with pain assessment, nutritional screening and screening tests for cognitive function evaluation. We have discussed these scales further in the text. The first part of the research part of this diploma paper was carried out in the form of a qualitative survey based on semi-structured interviews with nurses, working in the traumatology department. The interviews included basic and supplementary questions which were asked later, in case of need during the interviews with interviewees. The survey was conducted in April, in a trauma center in the Czech Republic. After finishing the interviews, the results were examined into detail by coding and categorization. The most important answers of the respondents were shown in the diagrams, which were created according to the defined categories. For the second group, a quantitative research, conducted in the form of an anonymous survey, was chosen - a survey with 50 respondents. This technique was chosen as a support for the received qualitative data. The goal of this thesis was to find out the use of assessment scales for evaluation of a patient in traumatology and at the same time to map the nurses´ point of view of the issue of using assessment scales in traumatology. To achieve the goal, following questions were formulated. RQ1: What assessment scales are used in traumatology for evaluation of patients? RQ2: How can the assessment scales contribute to improving the patient care? RQ3: Are the assessment scales actively used for determining the patient care intervention? RQ4: What is the opinion of nurses on using the assessment scales in traumatology? RQ5: What assessment scales are comfortable and beneficial for nurses to use in traumatology? During the research was found out that using of assessment scales results into improving the patient care, it helps us to regularly evaluate patient´s condition and to assess the risks the patient is during his/her hospitalization, endangered with. Although the nurses see the scales as beneficial, the scales are just another administrative burden for nurses in the traumatology department. However, the results of these scales are actively used to determine suitable intervention.

Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the quality of documentation of patient care in nurses' notes in a home health agency in central Texas. A retrospective audit of quality of nursing documentation using the Nurse and Midwifery Content Audit Tool (NMCAT) was done. A pre- and posttest design was used. A convenience sample of de-identified nurses' notes (80 pre- and 80 post) was selected from active patient records in the agency (n = 160). Descriptive and inferential statistics from the project showed that there was improved quality for the 15 criteria representing quality nursing documentation. After the educational intervention, documentation of patient's status if changed or unchanged improved to 80%, and patient's response to treatment improved (57% to 85%), entries were written as incidents occurred improved (53% to 64%). The nurse refers to the patient by name improved (0% to 66%). These findings were an indication of practice change, validating the need for periodic audits of nurses' notes in the agency in order to demonstrate compliance with quality standards. Based on the project findings, a retraining program is recommended to improve structured nursing documentation in a home health agency. This project is likely to contribute to social change as it enhanced the information communicated to other health care providers, coordination of care, and patient outcomes.

The overall aim of this thesis was to develop, test and use a simple, clinically useful instrument for the nutritional screening of older patients. Four studies were performed, with a quantitative approach, in a geriatric rehabilitation ward in western Sweden. The number of patients who par-ticipated was: 56 (I), 114 (II), 147 (III) and 144 (IV) older patients. A nutritional screening instrument, the Nutritional Form For the Elderly (NUFFE), was constructed (I) and tested regarding reliability and validity (I, II). NUFFE was used in a screening, and the screening results were related to the patients’ perceived health and compared to the nurses’ nutritional notes in the nursing documentation (III). The screened patients’ self-care ability and sense of coherence (SOC) were investigated and the patients’ perceived health was related to selfcare ability and SOC (IV). The collection of data was done through interviews with the instruments NUFFE (I-IV), the Selfcare Ability Scale for the Elderly (SASE) (IV), Antonovsky’s SOC scale (IV), a question about perceived health, healthrelated ques-tions (III, IV) and background variables (I-IV). Weight and height were measured (I-III). The nurses’ nutritional notes in the nursing documentation were collected (III). The screening instrument contains 15 threepoint items on ordinal level. The total score ranges between zero and 30 and a higher score indicates higher risk for undernutrition. Evidence of reliability and validity was shown (I, II). The determined cut-off points of NUFFE for identification of patients at low, medium and high risk for undernutrition were set to scores of <6, ≥6 and ≥13 (III). The screening results showed that 31% of the patients were identified to be at low risk for undernutrition, 55% at medium risk and 14% at high risk. When the screening results were compared to nurses’ nutritional notes in the nursing documentation, it was shown that important nutritional issues were absent in many patient records (III). The patients at high risk were more likely to perceive ill health than were those at low risk for undernutrition (p=0.03) (III). Those at medium or high risk were more likely to perceive ill health (p=0.014) and to have lower self-care ability (p<0.001) and weaker SOC (p=0.007) than were those at low risk for undernutrition. To perceive good health was associated with higher self-care ability (p<0.001) and stronger SOC (p<0.001). Lower self-care ability, being single and having been admitted from another hospital ward were three obtained predictors for being at medium or high risk for undernutrition (IV). In conclusion, NUFFE is a simple, useful screening instrument for identification of older nutritional at-risk patients. The instrument has sufficient evidence of reliability and validity. Using NUFFE in a screening of older patients, the prevalence of patients at medium or high risk for undernutrition was found to be high. Nurses’ nutritional notes showed deficiencies, indicating that all medium or high risk patients were not identified. Using NUFFE, associations were found between older patients’ nutritional risk and their perceived health, and their self-care ability and SOC, respectively. These associations indicate that being at low risk for undernutrition is concomitant with perceived good health, higher self-care ability and stronger SOC. Conversely, being at medium or high risk for undernutrition is concomitant with perceived ill health, lower self-care ability and weaker SOC.

<p>This dissertation aimed to investigate the use of electronic nursing documentation as a strategy to improve the quality of care provided to hospitalized patients. The literature to support the use of electronic nursing documentation on the quality of care delivered to patients is limited to date. Additionally, the literature describing the use of information for the delivery of care on paper-based nursing documentation is limited. This dissertation reviews the current literature, investigated the knowledge needed for nurses to know their patients and established categories of nurses' information needs as preliminary work to be able to descriptively compare the use of paper with electronic nursing documentation on inpatient care units within a hospital setting. The main study conducted for this investigation used a mixed-methods multiple case study design, to describe the processes of information use on two inpatient care units, while first using paper and subsequently electronic nursing documentation. Findings revealed the importance of the categories of nurses' information needs for both cases in addition to the use of verbal, paper-based and electronic information sources for the collection, communication and temporary storage of information needs. Additionally, the conversion to electronic nursing documentation introduced new challenges related to three quality metrics: efficiency, timeliness and safety. Recommendations are provided for further evaluation of electronic health records with additional consideration for appropriate hardware devices in the context of the care environment.</p> / Dissertation

Evidenced based nursing seeks to integrate new knowledge from current research into practice. The use of clinical practice guidelines is one method of accomplishing this. The purpose of this study was to assess the effect of differing clinical practice guideline representation formats on the quality of nursing care plans and on the experiences of nurses. To accomplish this, an experimental study taking place in a laboratory setting was executed. BC Cancer Agency nurses volunteered as the participants. The nurses were given case scenarios and asked to generate nursing care plans with the assistance of clinical practice guidelines. The clinical practice guidelines were presented in two formats: Portable Document Format (PDF) and Web Based Interactive (WBI). The quality of the care plans was rated using a validated evaluation tool. Participants were asked to ‘think-aloud’ during the care planning process and their experiences were recorded, transcribed, and analyzed through a cognitive task analysis. This study revealed advantages and disadvantages to both formats and provided insight into nurses' experiences. This study also showed no statistically significant difference in the quality of care plan documentation, regardless of clinical practice guideline format. This study highlights the importance of evaluating health informatics projects in healthcare settings to ensure positive outcomes in measures of user experience and measures of documentation quality. / Graduate / 0569 / 0758 / 0984 / csimad@gmail.com

SAMMANFATTNING Syfte: Syftet med detta arbete var att undersöka sjuksköterskors uppfattning om omvårdnadsdokumentation och dess påverkan på omvårdnadsarbetet. Metod: Kvalitativ intervjustudie med innehållsanalys enligt Lundman och Hällgren Graneheim (2008). Bekvämlighetsurval med fem sjuksköterskor från olika avdelningar på ett Universitetssjukhus i Mellansverige. Resultat: Sjuksköterskor i denna studie uppfattade att dokumentationen tar tid, det är mycket som ska dokumenteras och att kvalitén varierade. De uppfattade också att information kunde gå förlorad på grund av att många skrev på flera olika ställen. Dokumentationen upplevdes ibland som inkonsekvent eftersom sjuksköterskorna inte dokumenterade exakt lika. De belyste också att systemet var rörigt och ologiskt. Dokumentationen upplevdes ge vägledning. Det är viktigt att samarbeta mellan olika professioner samt att dokumentationen följs upp av den som tar efter. Sjuksköterskorna prioriterade det medicinska framför omvårdnaden och arbetsbördan gjorde det svårt att hinna dokumentera. Dokumentationen synliggjorde omvårdnaden samt att den kunde användas för att utvärdera vården. Slutsats: Sjuksköterskor uppfattade dokumentation som problematisk och tidsödande. Samtidigt tyckte de att det fanns vinster med dokumentation då det gav patientsäkerhet och kunde användas för att utvärdera vården. Mer arbete behövs för att nå konsensus i hur dokumentation på avdelning skall se ut. Det behövs mer forskning kring hur dokumentation påverkar omvårdnadsarbetet. / ABSTRACT Aim: The aim of this study was to investigate nurses’ perception of nursing documentation and its impact on nursing. Method: Qualitative interview study with content analysis according to Lundman and Hällgren Graneheim (2008). Convenience sample of five nurses from different wards of a University hospital in central Sweden. Result: Nurses in this study perceived the documentation as time consuming, there is a lot to be documented and that the quality varied. They also observed that the information could be lost due to many writing in several different places. The documentation is sometimes perceived as inconsistent because nurses did not document exactly alike. They also highlighted that the system was messy and illogical. Documentation was perceived as giving guidance. It is important to cooperate between different professions and that the documentation is followed up by the next person. The nurses prioritized the medical instead of nursing care and workload made ​​it difficult to find time to document. Documentation made​​ nursing care visible and it could be used to evaluate healthcare. Conclusion: Nurses perceived documentation as problematic and time consuming. They also thought there were gains of documentation when it gave patient safety and could be used to evaluate care. More work is needed to reach consensus in the documentation should be carried out. More research is required on how documentation affects nursing.

Topic of the diploma paper: Nursing Documentation in the Czech Republic. The paper compares nursing documentations used in various health-care establishments. Examining their printed form, it takes their main parts and focuses on the contents of individual components and on the records of implementation of the nursing process. These areas are analyzed and compared in the practical part of the paper. The objective of the diploma paper was to ascertain what documentation is used by health-care establishments in the Czech Republic and to compare these internal materials. From 49 contacted establishments in all regions of the Czech Republic, the research covered 15 establishments that consented to cooperation and provided nursing documentation in a printed form. All obtained materials were analyzed and used in research. In order to attain the objectives, qualitative research was used. A record sheet, based on 12 areas of the Gordon{\crq}s model, was made up for the purposes of the comparison. Individual documentations were kept and processed, and are referred to in the paper under letters of the alphabet so that anonymity of the research is maintained. Individual materials were analyzed. The contents of the sheets were compared and evaluated. The collected data were processed by means of Microsoft Office Word program. From the results of the research it is apparent that the documentations maintained by all the health-care establishments have a similar composition. They contain the nursing anamnesis, nursing care plan and other documents examined in detail in the paper. The nursing anamnesis is divided into individual fields that are not based on any mode and whose number varies. Measuring techniques are used in the documentations. The most widespread was Barthel{\crq}s test of activities of daily living. A nursing anamnesis is connected with a nursing care plan. All 15 documentations contain this plan. Six health-care establishments decided for a free form, six establishments for a preprinted form and the last three establishments combined the printed and the free form into one. According to the findings, all the examined samples are on a comparable level and comply with all the criteria of quality care of a patient, given by the needs of practice. The results of the paper will be provided to the cooperating establishments that may use them in order to achieve better quality of patient records.