Struktur og rutinar, — naudsynte føresetnader for å sikra sjukepleie—dokumentasjonen

The article presents extracts of a project started in 2005, focusing on nursing documentation of healthcare services in one of the smaller districts in Norway. A new quality control procedure was developed to provide comprehensive guidance for how patient journals should be organised, written and used in practice. A variety of interventions were carried out, both to make the procedure known and to increase the documentation skills of personnel. One year after the project had begun an initial evaluation was carried out. A questionnaire was sent to all employees. The feedback from the evaluation showed a positive change in that 84.6% felt that nursing documentation is valuable for the professional service, and there is greater awareness of the professional and legal responsibilities of nursing personnel in regard to documentation. The findings also show that there is confusion and insufficient knowledge about distribution of responsibility in regard to how the integrity of nursing documentation should be ensured, and that there is a need for continued training in the writing of nursing plans.