Quality of recording has an impact on the quality and safety of care

Authors

• Ulla-Mari Kinnunen Department of Health and Social Management, University of Eastern Finland, Kuopio; The wellbeing services county of North Savo, Kuopio
• Minna Mykkänen The wellbeing services county of North Savo, Kuopio
• Timo Ukkola Ministry of Finance, Helsinki
• Pia Liljamo Finnish Institute for Health and Welfare

DOI: https://doi.org/10.23996/fjhw.159773

Keywords:

Documentation, Nursing, Electronic health records, (Health) Information system, Informatics, Terminology as Topic

Abstract

Nursing documentation is an essential part of nursing and necessary to ensure safe and high-quality care. It ensures that patient care information is up-to-date and accessible to all members of the healthcare team, guaranteeing continuity of care. The information produced in patient records about events during patient care serves as legal documents that protect both patients and healthcare staff. Additionally, documentation allows for monitoring the patient's condition and the progress of care, helping to make informed care decisions and improve the quality of care and patient safety.
The national nursing documentation model consists of key structured nursing data elements (nursing diagnosis, interventions and outcomes, nursing care intensity, and nursing summary), the nursing process, and the Finnish Care Classification (FinCC). By documenting nursing according to the national nursing documentation model, the legal requirement for planning, implementing, monitoring, and evaluating patient care, as well as providing a nursing summary, is fulfilled. The entries must indicate how the care was carried out, whether anything special occurred during the care, and what care-related decisions were made during it. At the same time, information is produced about the content of nursing in operational units, which also describes the competence requirements, training needs, and provides feedback on the performance of nursing staff in clinical nursing.
Structured data and consistent terms bring structure and clarity to documentation and support the secondary use of information to enhance organizational efficiency and decision-making, including in management, research, and education. However, it has been noted nationally that social and healthcare information is not optimally utilized for prevention, improving care quality, or achieving cost-effectiveness and impact.
The maintenance and development of FinCC is the responsibility of the Department of Health and Social Management at the University of Eastern Finland, under the name Nursing Terminology Project. According to the cooperation agreement, the Finnish Institute for Health and Welfare is responsible for publishing the FinCC classification system for national use. The FinCC expert group continuously works on development.