Aim: The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses' experiences of documentation.
Method: This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n=102 and n=92, respectively] were carried out and 126 district nurses answered questionnaires pre-intervention and 83 post-intervention.
Result: The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses' opinions. Furthermore, the district nurses' self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses' experiences of documentation in general between the two groups.
Conclusion: Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.