International Journal of Medical Informatics
Volume 78, Issue 9 , Pages 605-617 , September 2009

Advancing nursing documentation—An intervention study using patients with leg ulcer as an example

  • Eva Törnvall

      Affiliations

    • Department of Social and Welfare Studies, Faculty of Health Sciences, University of Linköping, Campus Norköping, SE 60174 Norrköping, Sweden
    • Corresponding Author InformationCorresponding author. Tel.: +46 708 707724; fax: +46 11 125448.
  • ,
  • Lis Karin Wahren

      Affiliations

    • Department of Social and Welfare Studies, Faculty of Health Sciences, University of Linköping, Campus Norköping, SE 60174 Norrköping, Sweden
  • ,
  • Susan Wilhelmsson

      Affiliations

    • R & D Department of Local Health Care, County Council of Östergötland, SE 58185 Linköping, Sweden
    • Tel.: +46 13 228511; fax: +46 13 228501.

Received 10 March 2008 ,Revised 19 October 2008 ,Accepted 7 April 2009.

References 

  1. SFS 1985:562 Patientjournallagen (The Swedish Patient Record Act), in: Swedish, 1985, Statens författningssamling http://www.riksdagen.se/webbnav/index.aspx?nid=3911&bet=1985:562 2007-08-30 14.15 (in Swedish).
  2. Simpson RL. The role of IT in health care quality assessment. Nursing Administration Quarterly. 2003;27(4):355–359
  3. Brown G. Wound documentation: managing risk. Advances in Skin & Wound Care. 2006;19:155–165
  4. Iakovidis I. Towards personal health record: current situation, obstacles and trends in implementation of electronic health care record in Europe. International Journal of Medical Informatics. 1998;52:105–115
  5. Tornkvist L, Gardulf A, Stendler L-E. The opinions of district nurses regarding the knowledge, management and documentation of patients with chronic pain. Scandinavian Journal of Caring Sciences. 1998;(12):146–153
  6. Griffiths J, Hutchings W. The wider implications of an audit of care plan documentation. Journal of Clinical Nursing. 1999;(8):57–65
  7. Ehrenberg A, Birgersson C. Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district. Scandinavian Journal of Caring Sciences. 2003;(17):278–284
  8. Törnvall E, Wilhelmsson S, Wahren LK. Electronic nursing documentation in primary health care. Scandinavian Journal of Caring Sciences. 2004;18(3):310–317
  9. Carnevali DL. Handbok i omvårdnadsdiagnostik [Handbook for Nursing Diagnosis]. Stockholm: Liber; 1999;
  10. Olsson PT, Gardulf A. Nurses and head nurses views of nursing diagnoses at a geriatric clinic. Journal of Clinical Nursing. 2006;15:1338–1339
  11. Bäck-Pettersson S, Björklund C. Care of elderly lower limb amputees, as described in medical and nursing records. Scandinavian Journal of Caring Sciences. 2005;19:337–343
  12. Hyde A, Tereacy M, Scott A, Butler M, Drennan J, Irving K, et al. Modes of rationality in nursing documentation: biology, biography and the ‘voice of nursing’. Nursing Inquiry. 2005;12:66–77
  13. Lorimer KR, Harrison MB, Graham ID, Friedberg E, Barbara D. Venous leg ulcer care: how evidence-based is nursing practice. Journal of Wound, Ostomy, and Continence Nursing. 2003;30(3):132–142
  14. Johnson M, Bulechek G, Howard B, Dochterman McCloskey J, Maas M, Moorhead S, et al. NANDA, NOC, and NIC Linkages Nursing Diagnoses, Outcomes, & Interventions. St Louis Missouri: Mosby, Elsevier; 2006;
  15. International Council of Nurses, International Classification for Nursing Practice ICNP Version 1.0, International Council for Nurses, Geneva, 2005.
  16. Pesut DJ, Herman J. Clinical Reasoning, The art & science of critical & creative thinking. USA: Delmar Publisher; 1999;
  17. Thoroddsen A, Ehnfors M. Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation. Journal of Clinical Nursing. 2007;16:1826–1838
  18. Sansoni J, Giustini M. More than terminology: using ICNP to enhance nursing's visibility in Italy. International Nursing Review. 2006;53:21–27
  19. Thoroddsen A. Applicability of the nursing interventions classification to describe nursing. Scandinavian Journal of Caring Science. 2005;19:128–139
  20. Swedish Board of Health and Welfare, Övergripande kvalitetsindikatorer inom hälso- och sjukvård, Socialstyrelsens förslag (Suggestion for overarching indicators of quality in the Health care service), Socialstyrelsen, Stockholm, 2001 (in Swedish).
  21. Maylor ME. Establishing nurses’ preferences in wound assessment: a concept evaluation. Journal of Clinical Nursing. 2006;15(4):444–450
  22. Ribu E, Haram R, Rustoen T. Observation of nurses’ treatment of leg and foot ulcers in community health care. Journal of Wound, Ostomy, and Continence Nursing. 2003;30(6):342–350
  23. Björvell C, Thorell-Ekstrand I, Wredling R. Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care. 2000;(9):6–13
  24. Kirkwood B, Sterne JAC. Essential Medical Statistics. 2nd ed.. Massachusetts: Blackwell Science; 2003;
  25. Streiner D, Norman G. Health Measurement Scales a Practical Guide to Their Development and Use. 3rd ed.. Oxford: Oxford University Press; 2003;
  26. Bowman GS, Thompson DR, Sutton TW. Nurses’ attitudes towards the nursing process. Journal of Advanced Nursing. 1983;(8):125–129
  27. Newton C. A study of nurses’ attitudes and quality of documents in computer care planning. Nursing Standard. 1995;9(38):35–39
  28. Ehrenberg A. Nurses’ perceptions and practice concerning patient records in Swedish nursing home, Vard i Norden. Nursing Science and Research in the Nordic Countries. 2001;21(21):9–14
  29. Hjelm K, Nyberg P, Apelqvist J. Chronic leg ulcers in Sweden: a survey of wound management. Journal of Wound Care. 2000;9:131–136
  30. Franks PJ, Moffatt CJ. Do clinical and social factors predict quality of life in leg ulceration?. Lower Extremity Wounds. 2006;5(4):236–243
  31. Vowden KR, Vowden P. Preventing venous ulcer recurrence, a review. International Wound Journal. 2006;3(1):11–21
  32. Ehnfors M, Thorell-Ekstrand I, Ehrenberg A. Towards basic nursing information in patients records. Vard i Norden Utveckling Forskning. 1991;21:12–31
  33. Ehrenberg A, Ehnfors M, Thorell-Ekstrand I. Nursing documentation in patient records: experience of the use of the VIPS model. Journal of Advanced Nursing. 1996;24:853–867
  34. Graham I, Harrison MB, Lorimer K, Pierscianowski T, Friedberg E, Buchanan M, et al. Adapting national and international leg ulcer practice guidelines for local use: the Ontario leg ulcer community care protocol. Advances in Skin & Wound Care. 2005;18:307–318
  35. The South-eastern region CCiÖ, Jönköping and Kalmar, Svårläkta sår, Vårdprogram för sydöstra sjukvårdsdistriktet., Slow healing wounds, Care programme for south-eastern health region, 2005.
  36. Handbook for personnel in health care, chapter Ulcer treatment, Handbok för hälso-och sjukvård kapitlet Sårbehandling, http://www.sjukvardsradgivningen.se/handboken/default.htm, 2006-09-15 (in Swedish).
  37. Persoon A, Heinen MM, van der Vleuten CJ, de Rooij MJ, van de Kerkhof PC, van Achterberg T. Leg ulcers: a review of their impact on daily life. Journal of Clinical Nursing. 2004;13:341–354
  38. Snyder RJ. Venous leg ulcers in the elderly patient: associated stress, social support, and coping. Ostomy/Wound Management. 2006;52(9):58–68
  39. Jones J, Barr W, Robinson J, Carlisle C. Depression in patients with chronic leg ulceration. British Journal of Nursing. 2006;15(11):17–23
  40. Ebbeskog B, Ekman S-L. Elderly persons’ experiences of living with venous leg ulcer: living in dialectal relationship between freedom and imprisonment. Scandinavian Journal of Caring Sciences. 2001;15:235–243
  41. Patel GK. The role of nutrition in the management of lower extremity wounds. Lower Extremity Wounds. 2005;4(1):12–22
  42. Heinen MM, van Achterberg T, Scholte op Reime W, van de Kerkhof PC, de Laat E. Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions. Journal of Clinical Nursing. 2004;13(3):355–366
  43. Peters J. A review of factors influencing nonrecurrence of venous leg ulcers. Journal of Clinical Nursing. 1998;7:3–9
  44. Björvell C, Wredling R, Thorell-Ekstrand I. Improving documentation using a nursing model. Journal of Advanced Nursing. 2003;43(4):402–410
  45. Yura H, Walsh MB. The Nursing Process: Assessing, Planning, Implementing, Evaluating. 5th ed.. Norwalk: Appleton & Lange Corp.; 1988;
  46. AstraZeneca, Smärtanalys [Pain analysis], http://www.smarta.nu/upload/smarta/pdf/smartanalys.pdf, 2005, 2007-01-16 (in Swedish).
  47. Guigoz Y, Vellas B, Garry P. Mini nutritional assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts and research in Gerontology. 1994;(Supplement 2):15–59
  48. M. Unosson, A.-C. Ek, U. Wissing, M. Bachrach-Lindström, L. Christensson, A. Saletti, Handledning till nutritionsbedömning med Mini Nutritional Assessment (MNA), www.vardalinstitutet.net, Näring och ätande, Vårdalinstitutets tematiska rum, 2004.
  49. Broman J-E, Smedje H, Mallon L, Hetta J. The Minimal Insomnia Symptom Scale (MISS): a brief measure of sleeping difficulties. Upsala Journal of Medical Sciences. 2008;113(2):131–142
  50. Altman DG. Practical Statistics for Medical Research. London: Chapman & Hall; 1999;
  51. Irving K, Treacy M, Scott A, Hyde A, Butler M, MacNeela P. Discursive practices in documentation of patients assessment. Journal of Advanced Nursing. 2006;53(2):151–159
  52. K. Eriksson, T. Nordman, I. Myllimäki, Den trojanska hästen – evidensbaserat vårdande ur ett vårdvetenskapligt perspektiv, Institutionen för vårdvetenskap, Åbo Akademi, Vasa, 1999.
  53. Müller-Staub M, Lavin MA, Needham I, van Achterberg T. Nursing diagnoses, interventions and outcomes—application and impact on nursing practice: systematic review. Journal of Advanced Nursing. 2006;56(5):514–531
  54. Clark J, Lange N. Nursing's next advance: an international classification for nursing practice. International Nursing Review. 1992;39:109–111+128
  55. Ekman I, Ehrenberg A. Fatigued elderly patients with chronic heart failure: do patients reports and nurse recordings correspond?. International Journal of Nursing Terminologies and Classifications. 2002;13(4):127–136
  56. Axelsson L, Björvell C, Mattiasson A, Randers I. Swedish registered nurses’ incentives to use nursing diagnoses in clinical practice. Journal of Clinical Nursing. 2006;15:936–945
  57. Monsen K, Fitzsimmons L, Lescenski B, Lyttoon A, Schwichtenberg L, Martin K. A public health nursing informatics data-and-practice quality project. Computers, Informatics, Nursing. 2006;56:152–158
  58. Nilsson U-B, Willman A. Evaluation of nursing documentation—a comparative study using the instrument NoGA and Cat-ch-ing after an educational intervention. Scandinavian Journal of Caring Sciences. 2000;(14):199–206
  59. Björvell C, Wredling R, Thorell-Ekstrand I. Long-term increase in quality of nursing documentation: effects of a comprehensive intervention. Scandinavian Journal of Caring Sciences. 2002;(16):34–42
  60. Polit DF, Beck CT. Nursing Research: Principles and Methods. 7th ed.. Philadelphia: Lippincott Williams & Wilkins; 2004;

PII: S1386-5056(09)00056-2

doi: 10.1016/j.ijmedinf.2009.04.002

International Journal of Medical Informatics
Volume 78, Issue 9 , Pages 605-617 , September 2009