Dissertations / Theses on the topic 'Omvårdnadsprocess'
Create a spot-on reference in APA, MLA, Chicago, Harvard, and other styles
Consult the top 31 dissertations / theses for your research on the topic 'Omvårdnadsprocess.'
Next to every source in the list of references, there is an 'Add to bibliography' button. Press on it, and we will generate automatically the bibliographic reference to the chosen work in the citation style you need: APA, MLA, Harvard, Chicago, Vancouver, etc.
You can also download the full text of the academic publication as pdf and read online its abstract whenever available in the metadata.
Browse dissertations / theses on a wide variety of disciplines and organise your bibliography correctly.
Gunnarsson, Emma, and Sandra Persson. "Sjuksköterskors möjligheter till att utföra omvårdnadsdokumentation : Litteraturstudie." Thesis, Högskolan i Gävle, Avdelningen för hälso- och vårdvetenskap, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:hig:diva-19413.
Full textLewis, Josephine, and Ida Fredhage. "Sjuksköterskans identifiering, omvårdnadsproblem samt omvårdnadsåtgärder vid neglect : En intervjustudie." Thesis, Högskolan i Gävle, Avdelningen för hälso- och vårdvetenskap, 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:hig:diva-18042.
Full textForsström, Tove, and Linnéa Malmbo. "Sjuksköterskans arbete i övergången till palliativ vård : En litteraturöversikt." Thesis, Mittuniversitetet, Institutionen för hälsovetenskap, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-18894.
Full textWaxell, Anni. "Att vandra tillsammans mot frihet : Personers levda erfarenheter av att vara delaktig i sin omvårdnadsprocess, inom öppen rättspsykiatrisk vård." Thesis, Mälardalens högskola, Akademin för hälsa, vård och välfärd, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:mdh:diva-54104.
Full textKonovalova, Anastasia, and Linnéa Lissel. "Sjuksköterskors uppfattning om dokumentation och dess påverkan på omvårdnadsarbetet." Thesis, Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap, 2013. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-192120.
Full textABSTRACT Aim: The aim of this study was to investigate nurses’ perception of nursing documentation and its impact on nursing. Method: Qualitative interview study with content analysis according to Lundman and Hällgren Graneheim (2008). Convenience sample of five nurses from different wards of a University hospital in central Sweden. Result: Nurses in this study perceived the documentation as time consuming, there is a lot to be documented and that the quality varied. They also observed that the information could be lost due to many writing in several different places. The documentation is sometimes perceived as inconsistent because nurses did not document exactly alike. They also highlighted that the system was messy and illogical. Documentation was perceived as giving guidance. It is important to cooperate between different professions and that the documentation is followed up by the next person. The nurses prioritized the medical instead of nursing care and workload made it difficult to find time to document. Documentation made nursing care visible and it could be used to evaluate healthcare. Conclusion: Nurses perceived documentation as problematic and time consuming. They also thought there were gains of documentation when it gave patient safety and could be used to evaluate care. More work is needed to reach consensus in the documentation should be carried out. More research is required on how documentation affects nursing.
Johansson, Ann-Christin, and Emma Sundlöf. "Anestesisjuksköterskans erfarenhet vid svår intubation : En intervjustudie." Thesis, Högskolan i Borås, Institutionen för Vårdvetenskap, 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:hb:diva-17946.
Full textProgram: Specialistsjuksköterskeutbildning med inriktning mot anestesisjukvård
Svensson, Annsofie, and Hanna Wiberg. "Sjuksköterskors upplevelser av arbete med Weismananalys inom palliativ vård." Thesis, Malmö högskola, Fakulteten för hälsa och samhälle (HS), 2006. http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-26878.
Full textThe only thing we know for sure in life is that, some day, we will die, and that for some of us it is also about being taken care of in time of death. The aim of this study was to illuminate nurse’s experiences of working with a model for caring patients at a Hospice unit in the city of Malmö. This model emanates from the concept ‘psychological autopsy’ presented by Weisman and has been integrated as a part of the care of the dying patient. Data was collected using interviews with six nurses. The results show that the nurses found the model useful and valuable in two ways: (1) A shift of focus of their professional role, where they could see the patient from new perspectives and (2) it could be used as a tool in the daily nursing activities. This shift of focus seemed to mean that knowledge about the patients and their perspective became more important. There is also indication that the use of the model leads to a qualitatively better care.
Forsberg, Carin, and Maria Silén. "Operationssjuksköterskans upplevelse av återkoppling och återkopplingens betydelse för professionen." Thesis, Karlstads universitet, Institutionen för hälsovetenskaper, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:kau:diva-63555.
Full textIntroduction: Preventive and correctly taken nursing measures is part of the operating theatre nurse´s work. The operating theatre nurse´s work with the perioperative process by planning and implementing the nursing measures and evaluating them. Feedback has been shown to improve the care and develop the profession. There are few studies in the literature about the operating theatre nurses experience of feedback during the perioperative process. Aim: The aim of this study was to describe the operating theatre nurse´s experience of feedback and the importance of the feedback for the development of the profession. Method: A qualitative study with semi-structured questions has been analyzed with a qualitative content analysis. 11 operating theatre nurses in the age 26-60 years with the experiences an operating theatre nurse from 7 month to 36 years participated, all were women. Results: The operating theatre nurses experienced that it would be significant with more feedback, both for the development of the profession and to improve the evaluation of taken nursing measures. All feedback was positive. Lack of cooperation between care units affected the possibility of feedback negatively. The lack of feedback led them to seeking feedback of nursing measures by themselves. Conclusion: Through feedback the operating theatre nurses can get answer of their taken nursing measures. The feedback to the operating theatre nurses need to be implemented and develop in the daily work.
Bexell, Hanna, and Agnes Ulvegard. "Patientkännedom i den perioperativa vården : En intervjustudie med operationssjuksköterskor." Thesis, Karlstads universitet, Fakulteten för hälsa, natur- och teknikvetenskap (from 2013), 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:kau:diva-55128.
Full textIntroduction: The operating room nurse is responsible for a good and safe perioperative care. Preoperative person-centered information is a prerequisite to meet the patient´s unique needs and promote continuity of care. The patient´s individual risk factors are essential for the operating room nurse to know in order to prevent hospital acquired injuries and to accomplish safe perioperative care. Aim: The aim was to describe operating room nurses´ experiences of obtaining information to create knowledge of the patient in perioperative care. Method: A qualitative study with an inductive approach was conducted. Ten operating room nurses at a hospital in Sweden were interviewed. The interviews were recorded and transcribed. Content analysis was chosen as the method of data analysis. Result: Two generic categories emerged: Read written information about the patient and The preoperative meeting with the patient. These generic categories together form the main category Prerequisite for person-centered and safe perioperative care. The generic category Read written information about the patient includes the subcategories To acquire basic knowledge and To prioritize and to seize opportunities. The generic category The preoperative meeting with the patient includes the subcategories To meet and talk with the patient and To create conditions for conversation. Conclusion: The findings contribute to a deeper knowledge of what is essential to know about the patient in perioperative care and why this is important information, from the operating room nurse´s perspective. Both written information and a preoperative meeting with the patient are required to create prerequisite for person-centered and safe perioperative care. The results indicate a need of change in the way of working to enable good knowledge of each patient, and thereby increase patient safety in perioperative care.
Lundgren, Helena. "Perioperativa riskfaktorer för uppkomst av trycksår i samband med kirurgi : En litteraturstudie." Thesis, Högskolan i Gävle, Avdelningen för hälso- och vårdvetenskap, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:hig:diva-26419.
Full textBackground: Pressure ulcer prevention is a high priority for operating room nurses who care for the patient in the perioperative nursing phase. Nevertheless, the occurrence of pressure ulcers is relatively high in patients undergoing surgery.
Johansson, Ann, and Eva Lenander. "Förutsättningar för att kunna dokumentera enligt omvårdnadsprocessen." Thesis, Malmö högskola, Fakulteten för hälsa och samhälle (HS), 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-26155.
Full textAn adequate nursing documentation in a rapidly changing health and wellfare system is of great importance. Despite this the quality of nursing documentation is often described as poor. The aim of the literature study is to identify factors that influence the nursing documentation according to the five steps in the nursing process. A systematic literature review was conducted . A CINAHL, Cochrane Library and MEDLINE Database search was conducted and a manual search of the literature references completed the search. Ten articles were included and each study subjected to a quality assesment. To enable nurses to document according to the five steps of the nursing process, the results of the study indicates that knowledge of the nursing process, datorisation of documentation, the support and expectations of the management and nurses attitudes to the nursing process are vital factors.
Johansson, Ann, and Eva Lenander. "Förutsättningar för att kunna dokumentera enligt omvårdnadsprocessen." Thesis, Malmö högskola, Fakulteten för hälsa och samhälle (HS), 2007. http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-24353.
Full textAn adequate nursing documentation in a rapidly changing health and wellfare system is of great importance. Despite this the quality of nursing documentation is often described as poor. The aim of the literature study is to identify factors that influence the nursing documentation according to the five steps in the nursing process. A systematic literature review was conducted . A CINAHL, Cochrane Library and MEDLINE Database search was conducted and a manual search of the literature references completed the search. Ten articles were included and each study subjected to a quality assesment. To enable nurses to document according to the five steps of the nursing process, the results of the study indicates that knowledge of the nursing process, datorisation of documentation, the support and expectations of the management and nurses attitudes to the nursing process are vital factors.
Hansdotter, Linn, and Åsa Rappendal. "Äldre vårdtagares delaktighet i omvårdnadsprocessen : En systematisk litteraturstudie." Thesis, Högskolan Dalarna, Omvårdnad, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:du-4478.
Full textHultin, Dojorti Sandra. "Omvårdnads-dokumentation för patienter med höftfraktur : - En retrospektiv journalgranskning." Thesis, Umeå universitet, Institutionen för omvårdnad, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-183980.
Full textBackground: The quality of the nursing record can reflect the quality of nursing care provided to patients. Patients with a hip fracture often have an extensive need for care. The nursing record has an important function of describing the nursing process, nursing diagnoses and interventions. Patients with hip fractures often have complex health care needs and the nursing documentation can contribute to patient safety. The quality of the documentation increases with a structured journal. Furthermore, it should be written in a standardized language. Audit of nursing documentation can contribute to quality of care. Motive: Great health risks is a fact when suffering from a hip fracture, especially an already fragile person. The quality of the nursing documentation can contribute to better outcome in patient safety and the length of stay. Aim: To explore the quality of nursing documentation for patients with hip fractures. Methods: A retrospective descriptive and comparative design where audit of nursing records was used to attain the study's aim. A consecutive sample was used, where 40 patients’ health care records of nursing documentation for patients over the age of 60 with a hip fracture in an emergency orthopedic ward were included. The audit instrument Cat-ch-Ing was used. Result: The result showed that the quality was variable; none of the records had a complete documentation. Documentation of care plans were missing in a majority of the records. The documentation was of better quality in the group of younger elderly patients compared to that of older elderly patients. No quality differences were seen based on the length of stay. Conclusion: None of the records had a complete documentation. Further knowledge of how good quality nursing documentation on hip fractur patients can be implement for a sustainable result in clinical activities.
Kiyani, Ako, and Hanna Kumlin. "Psykiatrisk tvångsvårdPatienters erfarenheter av omvårdnadsprocessen i samband medpsykiatrisk tvångsvård." Thesis, Örebro universitet, Institutionen för hälsovetenskaper, 2019. http://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-75291.
Full textReinholdsson, Palmqvist Rebecca. "Sjuksköterskans intuition i vården samt dess betydelse för beslutsfattande i omvårdnadsprocessen." Thesis, Mittuniversitetet, Avdelningen för omvårdnad, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-25481.
Full textZetterlund, Sofia. "Sjuksköterskors erfarenheter av bedömningsinstrumentet : Klinisk slutexamination av sjuksköterskans vårdande utifrån omvårdnadsprocessen." Thesis, Högskolan i Borås, Akademin för vård, arbetsliv och välfärd, 2019. http://urn.kb.se/resolve?urn=urn:nbn:se:hb:diva-21968.
Full textHasselrot, Lottie. "Upplevelsen av att handleda sjuksköterskestudenter i omvårdnadsprocessen på en akutvårdsavdelning : en intervjustudie." Thesis, Sophiahemmet Högskola, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:shh:diva-1860.
Full textAndersson, Liselotte, and Päivi Jakum. "Inte som i Gökboet : sjuksköterskors beskrivningar av omvårdnadsprocessen inom den rättspsykiatriska vården : en kvalitativ studie." Thesis, University West, Department of Nursing, Health and Culture, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:hv:diva-1564.
Full textForensic psyhiatric care protects the society by giving patients care to diminish risks of serious crimes. In their work the nurses use different care methods to help and support the patient in managing his or her life situation. To clarify how a group of nurses describe the nursing process in forensic psychiatric care. A qualitative study based on interviews. Six nurses were interviewed about their work in four different forensic psychiatric care units. The nursing process in is divided into four categories: evaluation, planning, implementation and assessment. The results are based on the way the interviewed nurses described the essential roles of nurse-patient relationship and structured routines in nursing process. The study also shows some specific difficulties in nursing work, for example the mental dysfunctions of patients, the level of competence among staff and the patients need for social interaction and existence beyond their specific needs.
Busck, Håkans Vivéca. "Sjuksköterskors uppfattning om omvårdnadsdiagnostik." Thesis, Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap, 2011. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-155415.
Full textJacobsson, Marie. "Kan omvårdnadsprocessen användas för att öka petientens fysiska aktivitet och därmed minska risken för hjärt-/kärlsjukdom." Thesis, University West, Department of Nursing, 2002. http://urn.kb.se/resolve?urn=urn:nbn:se:hv:diva-959.
Full textLindblom, Katarina, and Angelica Örnberg. "Fördelar och nackdelar med standardiserad terminologi i sjuksköterskans omvårdnadsdokumentation : en litteraturöversikt." Thesis, Sophiahemmet Högskola, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:shh:diva-2527.
Full textLiljekvist, Korhonen Pernilla, and Lars Persson. "Omvårdnadsdokumentation : mer än bara ord." Thesis, Mid Sweden University, Department of Health Sciences, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-8797.
Full textBakgrund: Dokumentation innebär sammanställning av skriftliga underlag om ett visst objekt och/eller situation. Tydliga lagar styr sjuksköterskas dokumentationsplikt. Syfte: Syftet med denna litteraturöversikt var att belysa erfarenheter och upplevelser av sjuksköterskans dokumentation. Metod: Denna allmänna litteraturstudie med mixad design baserades på ett induktivt arbetssätt med systematisk ansats. Tolv relevanta artiklar hittades i databaserna PubMed och Cinahl. Artiklarna analyserades med manifest innehållsanalys. Resultat: Dokumentationen är ett underlag för omvårdnadsprocessen och stimulerar samarbete och informationsöverföring. Sjuksköterskans dokumentation påverkas av teknisk och språklig kunskap samt förståelse av planerade och utförda omvårdnadsåtgärder. Brister framkom också med att allt inte dokumenterades och detta innebar att viktig information kunde gå förlorad. Diskussion: Det är svårt att se legitima orsaker till bristande dokumentation. Kunskaper som krävs är inte svåra att införskaffa och tidsbrist är inte en godtagbar anledning till bristande dokumentation. Det som utförts eller planeras att utföras, av en sjuksköterska måste ofrånkomligen dokumenteras. Det ena blir inte komplett utan det andra. Synen på ändamålet med omvårdnadsdokumentationen och kunskap om teorierna bakom omvårdnadsbegreppen är det som styr hur bra dokumentationen blir. Slutsats: Omvårdnadsdokumentationen måste utvecklas och förbättras. Sjuksköterskor måste våga kritisera andras och diskutera sin egen dokumentation.
Grönvall, Maria, and Boberg Linda Jansson. "Metoder som lindrar patienters oro och ångest inför operation : en litteraturöversikt." Thesis, Högskolan Kristianstad, Sektionen för hälsa och samhälle, 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:hkr:diva-13715.
Full textHammar, Eric, and Fredrick Landervik. "Behöver ambulanspersonal veta? En enkätstudie om ambulanspersonals behov av uppföljning." Thesis, Högskolan i Borås, Institutionen för Vårdvetenskap, 2014. http://urn.kb.se/resolve?urn=urn:nbn:se:hb:diva-17940.
Full textProgram: Specialistsjuksköterskeutbildning med inriktning mot ambulanssjukvård
Brännström, Anna, and Lisa Gustavsson. "Omvårdnad av patienter med venösa bensår - en intervjustudie som beskriver distriktsköterskors strategier vid bensårsbehandling." Thesis, Umeå universitet, Institutionen för omvårdnad, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-111961.
Full textCannier, Linda. "Granskning av sjuksköterskans journalföring gällande emotionell hälsa hos patienter som genomgått allogen stamcellstransplantation." Thesis, Röda Korsets Högskola, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:rkh:diva-171.
Full textAccording to the Patient Act (SFS 2008:355), Chapter 3, § 1 has been determined that the nurse is required to keep records. Each health record shall contain a care plan which will be designed according to nursing process, five phases: assessment, diagnosis, goals, planning, implementation and evaluation. Nursing documentation is intended to describe the given care, what decisions and actions that have been taken and the results achieved. Patients undergoing allogeneic stem cell transplantation (SCT) often experience a high psychological distress and the time of transplantation is in itself complex, with many treatment- related side effects, both physically and mentally. The aim of the study was to investigate the nurse´s nursing documentation on nursing process to patient emotional health (EH) from the discharge date for SCT and one year ahead. 40 patient records were reviewed at a haematological reception, which is the reception which has responsibility for monitoring and follow-up care of patients undergoing allogeneic SCT. 73% of these 40 patients had at least one entry recorded in the journal about EH. 81% of documented records is about negative experiences. No patient had an established care plan, built according to nursing process known their EH and EH patients were described in 86% over the keyword welfare. Based on these results the author´s experience that the nurses at this clinic extensively documenting patients´ EH somewhere in the nursing journal, but that there is no planning of patient EH arising nursing process as a whole. Based on the result in the study, the author´s view is that all nurses should be given the opportunity to get training in nursing documentation in order to maintain and improve their knowledge.
Janback, Caroline, and Elin Petersson. "Utvärdering av omvårdnadsdokumentation i elektronisk patientjournal på kirurgisk vårdavdelning." Thesis, Uppsala University, Uppsala University, Department of Public Health and Caring Sciences, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-104865.
Full textSAMMANFATTNING
Syfte. Utvärdera omvårdnadsdokumentationens kvalité och omfattning i elektronisk patientjournal på kirurgisk vårdavdelning. Metod. De senaste 60 journalerna från två kirurgiska vårdavdelningar valdes ut genom bekvämt urval. Varje journal lästes och bedömdes av båda författarna. Varje steg i omvårdnadsprocessen utvärderades efter granskningsmall och bedömdes som fullständig, för omfattande eller ofullständig. Resultat. Standardvårdplan användes i alla granskade journaler. Antalet steg i omvårdnadsprocessen som fanns dokumenterade varierade mellan fem och nio. Anamnes, status och effekter av åtgärder fanns beskrivna i majoriteten av journalerna. I samtliga journaler fanns utförda åtgärder dokumenterade. Omvårdnadsepikris fanns i större delen av njurtransplantationsjournalerna, men inte alls i struma/hyperparatyroidism (HPT)-journalerna. Majoriteten av uppdaterade status bedömdes som ofullständiga. Sexton av struma/HPT-journalerna innehöll inte anteckningar i rapportbladet. Av dem som hade rapportbladsanteckningar bedömdes majoriteten vara för omfattande. Samtliga njurtransplantationsjournaler hade för omfattande anteckningar i rapportbladet. Ingen av journalerna hade en individuell vårdplan. Slutsats. Omvårdnadsdokumentationen i den elektroniska patientjournalen bedömdes som ofullständig då det inte gick att få en tydlig bild av patientens omvårdnadsproblem och omvårdnadsbehov. Kvalitén på dokumentationen behöver förbättras. Detta kan ske genom att minska dokumentationen i rapportbladet och istället använda standardvårdplan och uppdaterat status i större omfattning. Fortsatt utbildning och återkoppling krävs för att förbättra dokumentationen.
ABSTRACT
Aim. To evaluate the quality and extent of the nursing documentation in electronic health record on surgical ward. Method. The latest 60 health records from two surgical wards were selected by convenience sample. Both authors read each health record. Every step of the nursing process was evaluated with a nursing documentation audit and was classified as complete, too extensive or incomplete. Results. Standardized care plan was used in all electronic health records. Numbers of steps documented in the nursing process were five to nine. Nursing history, status and outcome were documented in most health records. Done interventions were documented in all health records. Goiter/hyperparathyroidism (HPT)-records had no nursing discharge note, while the kidney transplantation-records had one in almost every health record. Majority of updated statuses were evaluated as incomplete. Sixteen of the goiter/HPT-records had no notes of occasional matters, all kidney transplantation-records had too extensive notes. No individualized care plan was found. Conclusion. The total nursing documentation in the electronic health records were evaluated as incomplete. The quality of documentation needs to be improved. This can be achieved by less documentation of occasional matters, using the standardized care plan, updating status more often and further education and feedback.
Vejedal, Åsa. "Omvårdnadsdokumentation : granskning av omvårdnadsjournaler inom psykiatrisk slutenvård." Thesis, Högskolan Väst, Avd för specialistsjuksköterskeutbildning, 2011. http://urn.kb.se/resolve?urn=urn:nbn:se:hv:diva-3693.
Full textBergström, Jenny, and Hanna Brusling. "Sjuksköterskans dokumentation - Intervjuer av sjuksköterskor om deras uppfattningar av omvårdnadsdokumentation." Thesis, Malmö högskola, Fakulteten för hälsa och samhälle (HS), 2007. http://urn.kb.se/resolve?urn=urn:nbn:se:mau:diva-26808.
Full textBackground: The system for nursing documentation has changed since nurses require, by law to construct nursing records. This has led to patient care and nursing becoming more visible and can therefore be reviewed and controlled. Systems for improving patient care using models such as the VIPS and Melior has through time, developed. But the system for nursing documentation still requires development. Aim: The aim of the study was to explore nurses perceptions of nursing documentation. Method: A phenomenographic study was conducted through 11 interviews with nurses in a hospital in southern Sweden. Results: 244 perceptions were formulated. These were categorised into five main categories, and from these 12 sub categories were identified. The five main categories include: attention to details may prevent the purpose, what's not written, for whom does the nurse construct nursing records -and for whom doesn't she, documentation and safety of the patient, Melior and the VIPS-model.
Hellström, Jennie, and Ann-Katrin Pettersson. "Kvalitetsgranskning av omvårdnadsdokumentation i datoriserad patientjournal." Thesis, Uppsala University, Department of Public Health and Caring Sciences, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-111668.
Full textSyfte: Syftet med studien var att undersöka hur omvårdnaden dokumenteras i datoriserad patientjournal på en medicinavdelning i mellan Sverige, genom en journalgranskning med granskningsinstrumentet Cat-ch-Ing. Frågeställningarna var ”Vilka poäng ger Cat-ch-Ing instrumentet avseende kvantitet samt kvalitet?” och ”Kan omvårdnadsprocessen följas i omvårdnadsjournalen utifrån Cat-ch-Ing instrumentet?”
Metod: Studien är kvantitativ, deskriptiv och retrospektiv. En journalgranskning gjordes med hjälp av granskningsinstrumentet Cat-ch-Ing. Ett systematiskt urval av 100 journaler gjordes och därefter ett slumpmässigt urval av 30 journaler. Cat-ch-Ing instrumentet består av designade frågor som poängsätter sjuksköterskans dokumentation avseende kvantitet och kvalitet, samt hur omvårdnadsprocessen som helhet följs.
Resultat: Högst poäng avseende kvantiteten fick omvårdnadsepikrisen/slutanteckning och användandet av VIPS-sökord, medan omvårdnadsstatus uppdaterat under vårdtiden fick den lägsta poängen. Högst poäng avseende kvaliteten i dokumentationen fick användandet av VIPS-sökord och omvårdnadsstatus vid ankomst, medan vårdplanens omvårdnadsmål och omvårdnadsdiagnos fick de lägsta poängen. Resultatet visade att dokumentationen på medicinavdelningen följer omvårdnadsprocessens alla steg, då alla delar i omvårdnadsprocessen fick poäng avseende kvantitet i Cat-ch-Ing instrumentet.
Slutsats: Resultatet i den här studien tyder på att dokumentationen på medicinavdelningen generellt var bra, eftersom den har fått höga poäng i Cat-ch-Ing instrumentet. Omvårdnadsprocessens alla delar fanns med i dokumentationen. De brister som fanns förekom framförallt i vårdplanernas omvårdnadsdiagnoser, omvårdnadsmål samt i att uppdatera status. Kontinuerlig utbildning för all personal och uppföljning i form av journalgranskning behövs för att öka kvaliteten i omvårdnadsjournalen.