ORIGINAL ARTICLE zyx Structure and Content in Norwegian Nursing Care Documentation zyxw Torbjorg Aa. Stokke, Dr PH and Mary zyxwvu H. Kalfoss, RN, MA, RN, Cand. Nurs. Sci. From the Oslo College, Department of Nursing Education, Oslo, Norway Scand J Caring Sci 1999; 13: 18-25 In 1994, the Norwegian Board of Health (NBH) published recommendations for nursing care documentation. The two-fold purpose of the present study was to see if zyxwvutsrqpo 5 wards in 2 Norwegian hospitals fulfilled the proposed NBH recommendations and guidelines regarding documentation, and to evaluate them in terms of the proposed structure and key words of the VIPs model. Results showed that all nursing records (n = 55) had an admission assessment. A nursing care plan was present in 62% of the records. Nursing goals were lacking in the remaining 38%, diagnosis and planned interventions were absent in 18%, and zyxw 45% of the diagnoses lacked information concerning patient progress or outcome. The nursing care plans were updated in only 40% of the records and discharge notes were present in 35%. confirming that NBH recommendations were not met in this sample. The key words of the VIPs model covered all information present in the records, and high interrater reliability was obtained for the majority of key words categorized by two independent researchers. It is suggested that the VIPs model components and key words can contribute to a reliable and uniform model for nursing care documentation and enhance comprehensive and systematic documentation, which is presently lacking in Norwegian records. zyxwvutsrqpon Key words: nursing documentation, nursing care, nursing process, nursing records, nursing audit. Submitted 20 October 1997 Accepted zyxwvutsrqpon 16 Februury 1998 INTRODUCTION Nursing documentation is intended to promote individual- ized nursing care, maintain patient safety and care conti- nuity, and contribute to a common language framework for the communication of nursing care. Thus, the impor- tance of documentation in nursing has been the subject of consideration in international literature during the past years (1 -3). In Norway, however, documentation has only recently begun to receive considerable attention (4-6). The previous paucity of attention regarding Norwegian nursing documentation may be due to the fact that nursing documentation is not obligatory by law except for mid- wives. The Norwegian law regarding personal registers does not permit nurses in their own right to keep notes containing person-identifiable information. Fortunately, this view is presently under alteration. In 1994, the Norwe- gian Board of Health (NBH) published guidelines for nursing care documentation which are as follows: (i) the nursing record structure is to include 6 major areas com- posed of data collection, problem statement, purpose/ex- pectation as to nursing result, nursing interventions, evaluation/report of the patient’s condition in relationship to identified nursing goals and performed interventions, and a discharge summary; (ii) all professional patient zyxwvu 0 Scandinavian University Press, 1999. ISSN 0283-9318 information is to be kept in a common record, with nursing documentation filed separately; (iii) an individual nursing care plan is recommended, with revisions being made based on changing patient needs and resources; (iv) all written notes are to be signed and dated; (v) the documentation is to include physical, psychological, and social/cultural needs, to be related to the patient’s ability to cope with these needs (7, 8). One can conclude that the NBH recommendations are comparable to the components of the nursing process (9). VIPs model structure and content The VIPs model is a Swedish nursing documentation model which is presently undergoing validation and revi- sion (10, 11). The general aim of nursing care in this model is based on 4 key concepts: well-being, integrity, preven- tion, and safety, which form the acronym VIPs in Swedish spelling, and which represent basic nursing care values and the aim of the nursing process (1 1). The VIPs model contains a general structure quite similar to the NBH recommendations (Table I). The main elements (later termed ’components’) are labelled differ- ently than those suggested by the NBH. They include: nursing history, nursing status, nursing diagnosis, nursing Scund J Caring Sci