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Dokumentation i datajournal vid inskrivning på akutvårdsavdelning - En kvantitativ explorativ studie
Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science.
Jönköping University, School of Health and Welfare, HHJ, Dep. of Nursing Science.
2019 (Swedish)Independent thesis Basic level (degree of Bachelor), 10 credits / 15 HE creditsStudent thesisAlternative title
Documentation in the electronic health record when admitting a patient at an emergency care department - A quantitative exploratory study (English)
Abstract [sv]

All legitimerad personal inom hälso- och sjukvården är skyldiga att dokumentera. Noggrann dokumentation vid inskrivning utifrån checklistan leder till säker vård. Det som inte dokumenteras syns inte, är lätt att missa vid överrapportering och kan leda till lidande för patienten. Dokumentationen är central i kommunikationskedjan och ett hjälpmedel för all vårdpersonal.

Syfte: Syftet var att undersöka följsamhet till checklista vid inskrivning av patienter i samband med dokumentation i datajournal på medicinsk/geriatrisk akutvårdsavdelning. 

Metod: En kvantitativ och explorativ studie med deduktiv ansats genomfördes. Datainsamlingen bestod av journalgranskning utifrån en förutbestämd checklista som används vid inskrivning. Journalgranskningen utfördes på tio inneliggande patienters journaler på en medicinsk/geriatrisk akutvårdsavdelning på ett länsdelssjukhus i södra Sverige.

Resultat: Checklistan vid inskrivning följdes till ca 70 % på den medicin/geriatriska akutvårdsavdelning medan ca 30 % av sökorden i checklistan var dokumentation utförd på akutmottagningen. Dokumentationen fördes under relevant sökord.

Slutsats: Resultatet visade att sjuksköterskor på medicinsk/geriatrisk akutvårdsavdelning följde flertalet sökord utifrån checklistan vid inskrivningstillfället. Andra sökord i checklistan fanns redan dokumenterade från akutmottagningen när patienten kom upp till akutvårdsavdelningen. 

Abstract [en]

All licensed healthcare professionals have an obligation to document. Keeping an accurate documentation in the electronic health record leads to a patient-safe care. Documentation is key in the communication between healthcare professionals and an important tool in the care that is given.

Purpose: The purpose of the study was to investigate adherence to the checklist when documenting in the electronic health record in connection to admitting a patient at a medical/geriatric emergency care department.

Method: Quantitative exploratory reviews of electronic health records. A quantitative method with a deductive approach was used when processing data. Data collection consisted of electronic health record reviews based on the checklist used at admittance. The records viewed were those of patients admitted to an emergency care department at a district hospital in southern Sweden.

Results: 70% of the documentation from the checklist was kept at the medical/geriatric emergency department while the other 30% where documentation from the emergency room. Documentation was kept under the right search words.

Conclusion: Results showed that most keywords were followed by the nurses at the medical/geriatric emergency department and the missing keywords were already documented by nurses at the emergency room.

Place, publisher, year, edition, pages
2019. , p. 22
Keywords [en]
Admission checklist, medical record review, nursing documentation, nursing informatics, quantitative method
Keywords [sv]
Checklista vid inskrivning, informatik, journalgranskning, kvantitativ metod, sjuksköterskans dokumentation
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-43903ISRN: JU-HHJ-OMA-1-20190461OAI: oai:DiVA.org:hj-43903DiVA, id: diva2:1319441
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Available from: 2019-06-12 Created: 2019-05-31 Last updated: 2019-06-12Bibliographically approved

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