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Hoitotyön prosessin mukainen kirjaaminen ikääntyneiden laitoshoidossa

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Hoitotyön prosessin mukainen kirjaaminen ikääntyneiden laitoshoidossa

The aim of this study was to map out how registration in accordance with the process model of nursing is implemented at Kaunisjärvi Old-Age Home and at Linnavuori Service Centre. The goal was, by means of research, to find information on how the data recording in nursing can be developed to secure the rights of both a senior citizen and a nursing employee. Another goal was to make it possible to utilize the results when transferring to electronic registration based on the process model of nursing. The study aims at finding out what is recorded in nursing plans and daily documents, when the need for nursing is being defined, when goals are being set and planned, when helping methods within nursing are being materialized and when nursing is being evaluated. From the end of February till the beginning of March in 2007, a structured enquiry was addressed to the nursing staff (N=65) of Kaunisjärvi Old-Age Home. The response percentage of the enquiry was 69. A quantitative study was made on the nursing ward of Linnavuori Service Centre. In it, medical records (N=18) were investigated to determine how the registration of nursing had been implemented on the ward in November 2006. In the theoretical part of the thesis, the registration of the nursing process and the role of laws and regulations in that process were dealt with. In the empirical part, an attempt was made to determine how the nursing process is currently implemented in registration and what was the nursing staff’s own assessment on how they had succeeded in carrying out the recording process. According to the results of this research nursing documentation is different depending on whether it is studied as experienced by nursing staff or when it is studied from medical records. Frequently, medical records contain information different from that gained by nursing staff. According to the results of the study, recording is sufficient for determination of nursing needs. There were quite many goals in the medical records, although only one third of the respondents felt they were recording them regularly. More than one half of the respondents said they registered nursing diagnoses, but there were none in the medical records. The conrecte helping methods of nursing were registered well, whereas non-verbal methods were registered only seldom. The nursing staff told it had registered an estimate of a client’s state of health, but in the medical records there was no entry of such an estimate.

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