Nationally Standardized Electronic Nursing Documentation in Finland by the Year 2007

摘要

The electronic nursing documentation is not unified in Finland and it doesn't connect with nationally recommended multiprofessional core documentation of the patient history. The aims are to develop a nationally unified and standardized nursing documentation by the year 2007, to use the standardized nursing data to manage and assess the quality of the nursing process and to integrate the nursing documentation into the multiprofessional patient record.. The nationally defined structured nursing documentation is piloted in 23 health care organizations during 2005-2007 by the support of the Ministry of Social Affairs and Health. Piloting covers special care, primary care and homecare. The nursing process is used as a structure for the documentation. The classification components of The Finnish Nursing Intervention Classification [I] based on the Clinical Care Components developed in the United States by Dr. Virginia Saba [2] provide the structure for documenting nursing care. Classification for outcomes and the core data for nursing summary will be developed. Finnish Oulu Patient Classification (OPC) is used to measure the patient care intensity.