Högskolan i Skövde

Syftet med studien var att undersöka kommunsjuksköterskan omvårdnadsdokumentation om bensår i hemsjukvård. Som metod valdes journalgranskning. Resultatet visade att omvårdnadsdokumentationen brister på många sätt.

Background: In Sweden, approximately 50 000 people suffers from slow-healing leg ulcers. The number of municipal registered nurses ́ has decreased in recent years. The municipal registered nurses ́ often hold function as an advisory consultant for the nursing staff and without participating in nursing care. This documentation is based on second-hand information from the nursing staff. Purpose: The aim was to investigate how municipal registered nurse care documents about leg ulcers in patients in home care practice. Method: An audit of patient journals was chosen to investigate how municipal registered nurse ́ care documents about leg ulcers in patients in home care practice. Results: The results are presented in five themes: contact cause, health and medical history, skin functions alternatively skin / tissue, skin action alternatively action / prescription skin / tissue and Ulcer case record. Beneath these themes the assessment of documentation was into incomplete, partially complete and complete. The result shows that the municipal registered nurse often documents in chronological order and not applying to the nursing process. The results also showed that the old documentation was not completed in the journal, which meant that it was difficult to follow a course of treatment. Discussion: The result shows that documentation in home care failures in many ways. Municipal registered nurse works as a consultant and is not involved in daily care. The documentation is based on second-hand information from the nursing staff and resulting in the documentation of leg ulcers is poor. Patient journals documentation was divided into different keyword, which means that it was difficult to follow the nursing process.