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Rakenteisen kirjaamisen kehittäminen Lapinlahden kotihoidossa : Koulutustilaisuuden järjestäminen

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Rakenteisen kirjaamisen kehittäminen Lapinlahden kotihoidossa : Koulutustilaisuuden järjestäminen

Structured documentation in nursing care is coherent information in a patient information system that is in electronic format. Nursing care´s structured documentation is composed of nationally defined nursing care´s core information, process thinking and FinCC classifications. Nursing care´s core information is used to document nursing. The nationally defined core information of nursing care consists of the following parts: need of treatment, treatment action, treatment results, care intensity and the summary of the nursing care. Documentation is every health care profes-sional’s responsibility/obligation. Customer orientated approach and individual care is emphasized in documentation. Documentation aims to secure treatment continuance and information transmission which enhance customer and patient safety. Documentation also improves the aim of the treatment. Structured documentation helps to make nursing care transparent which supports quality assurance and development of nursing care.

The purpose of the thesis was to plan and organize a training of structured documentation for the home care personnel of the municipality of Lapinlahti. The subject of the thesis came about from working life. The thesis is a func-tional study, the output of which was two training events to the home care personnel of the municipality of Lapinlahti. There were also personnel from Lapinlahti residential care department and care department who participated in the training. The goal was to produce obvious benefit to the departments and to develop the personnel’s own documentation and training skills. Another goal was to improve the personnel’s documentation skills.

The information base for the thesis was collected from structured documentation, vocational skills demonstration in nursing and home care, relevant research, laws and regulations. The thesis was assigned by the home care de-partment of the municipality of Lapinlahti.

The trainings where arranged in October of 2016 as two separate afternoons that were two hours long. The trainings included the following parts: orientation, theory, a case type assignment, dismantling of the assign-ment and feedback. The theory part of the training dealt with the present situation of structured documentation in the department, goals that were set for the training, the advantages of structured documentation in nursing care, the risks of insufficient documentation, the criteria for documentation in nursing, the process model of nursing care , FinCC classification, vocational skills demonstration in nursing care and its documentation and evaluation, customer orientated documentation and the ethicalness of that documentation. The content of the training was illustrated with a Power Point presentation. In the end of the training the participants were asked to fill in feedback forms. The feedback forms´ questions were open-ended which ensured the feedback’s versatility. In addition to the training, with the help of Excel-table a miniguide was set up according to FinCC-classification. In future research it could be investigated how documentation has developed and how FinCC-classification is used.

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