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Hoitotyön yhteenvetojen tarkastelua FinCC- luokituksen avulla

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Hoitotyön yhteenvetojen tarkastelua FinCC- luokituksen avulla

The purpose of this Bachelor’s thesis work is to describe the contents of nursing summaries made in District Hospital medical ward. We describe the current state of nursing summaries by Finnish classification defined by the core data and also how the structural documentation can be seen in the nursing summaries. The goal of the analysis is to highlight the importance of systematic recognition of nursing summaries and how important properly fulfilled nursing summary is for the patients follow-up care. As a result of this thesis the material can be used to further develop the nursing summaries in the District Hospital. Our thesis is both qualitative and quantitative. The research material consists of fifteen nursing summaries. The material has been analyzed by using deductive,descriptive research method. At the theory part of this thesis is described the general nursing summary model in Finland, documentation template and related Finnish nursing FinCC -rating. This thesis also includes theory of nursing core data and it´s sub-regions. Our research revealed that the documentation was incomplete and inconsistent. Some of the components were not used at all or the data was at wrong fields. We found also that the documentation has been challenging. The need for training is obvious.

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