Patient records in nursing homes - Effects of training on content and comprehensiveness

The purpose of this study was to describe the effects on the contents and c omprehensiveness of the nursing-care documentation in the patient records a t nursing homes following an educational intervention, A review was made of records (n = 120) from nursing homes in sbr Swedish municipalities. alloca ted to a study group and a reference group. All the nursing home nurses in three municipalities received education concerning the nursing process and how to document according to the VIPS model. A retrospective audit of all n ursing notes in the records from the nursing homes was mode before and afte r the intervention. Improvements. were;cre found in the contents of the rec ords in the study group. The number of notes on nursing history more than d oubled. The occurrence of the recording of nursing diagnoses, goals and dis charge notes increased. No corresponding changes were observed in the refer ence group. in the study group, an increase in the number of acceptable not es with contents on nursing history, status, nursing diagnosis, planned and implemented interventions, and nursing discharge notes was found. This inc rease was significant. The comprehensiveness in the documentation of single nursing problems was only slightly improved in the study group, No record met the requirements of the national regulations on nursing documentation o r followed the nursing process thoroughly.