Kvalitet på elektronisk sykepleiedokumentasjon hos pasienter med hoftebrudd og helsetjenesteassosiert infeksjon

Abstract

Project background: Approximately 9000 patients with hip fractures are annually admitted to hospitals (Folkehelseinstituttet, 2016). About 50000 patients receive an annual health-related infectionthat cangive more number of bed nightsand an increasedrisk of mortality. Good infection control procedurescan prevent some of the health related infections (Helse-og omsorgsdepartementet, 2008b). Nursing for these patients consists of a pre-and a postoperative periodwhere observations of signs of complications are important(Knutstad, 2013). Research shows that nursing documentation in several cases is poor, both in relation to what has been the current patient problem and needs, and in relation to legal and professional requirements (Carlsson et al., 2012; Förberg et al., 2012; Gunningberg et al., 2008). The Norwegian Institute of Public Health measures twice the annual prevalence of health-related infectionsand the use of antibiotics (NOIS-PIAH) (Folkehelseinstituttet, 2011).Purpose and problem:The aimwas to decribethe quality of the nursing documentationperformed by nurses in the electronic healthcarejournal (EHR) for patients admitted to a hospital with hip fractures and an health related infection defined by NOIS-PIAH.Method:A quantitative method was used with record auditsand N-Catch II as an audit instrumentwas used. The resultsarepresented with descriptive statistics.Results:The results show that the care plan,the structured way fordocumenting with a standardized language,does not correspond to other documentation that emerges in the patient's evaluation in free text notes and the careplan is often not updated during their stay. Conclusion: The findings show that the documentation is inadequate. The documentation seems to be more challenging during the hospital stay, while the findings show that documentation made in admission reports and discharge reports are more complementary.Keywords:Nursing documentation, hipfracture, health-related infections, N-Catch, record audit