The structured nursing documentation system will be introduced at the Oulunkaari primary health care unit during 2014. The medical staff was educated about the new nursing documentation system throughout autumn 2013.

The purpose of this study was to determine what kind of nursing documentation practices were being used in Oulunkaari primary health care units. Furthermore, the objective was to examine if the medical staff was able to prepare the structural nursing care plan. The medical staff learned about how to make a structural nursing care plan during this Continuing Education. The objective of the study was also to provide them with feedback about how to make a nursing documentation in accordance with a nursing process and the FinCC – classification.

The study was based on both a quantitative and a qualitative research methods. The empirical section consists of exercises that the medical staff prepared before and during their training. In the preliminary exercises it was reported what kind of the nursing documentation practices were used in the health care units. These exercises were analyzed by using inductive content analysis and the results were specified by quantification. The medical staff was trained to make a nursing care plan according to the FinCC-classification during the Continuing Education. The plans were analyzed by using a ready to use evaluation form. The analysis method was deductive.

The results revealed that there were very different practices of nursing documentation in health care units. The differences were especially indicated in the documentations of cares in implementations, evaluations and interval evaluations. There were some aspects in the documentation of the nursing process that still should be developed, especially regarding the care targets and evaluation. Instead the steps of the nursing process were recorded well in the appropriate sections in the structured documentation system. There were some points that required improvements in this units, especially the preparation of the patient-oriented objectives and the estimation of the effectiveness and the results of the care methods.

The employees in these units will be able to use the results of this thesis when they introduce the model of the structured documentation system. The employees have the possibility to develop a nursing documentation system according to the model of nursing process by means of the results of this thesis. In addition to this, results could be used in order that documentation practice becomes convergent among the different units.