Distriktssköterskors dokumentation i omvårdnadsjournal vid telefonrådgivning.
The aim of the study was to describe what district nurses, who work with telephone- advice, document in patient record, to be able to develop their documentation. The Authors have examined 50 patient records. The examination tool is collected from ?Lokal anvisning för hälso- och sjukvården I Södra Älvsborg?. The audit areas was record keeping, review and planning, realization, individual nursing and the patients participation, information, education and agreement. The sample was stratified to avoid examining only one district nurses´ documentation. The sample was from, the five first and the five last telephone-advices that was documented in patient record, the five first days in July 2006. The result of the audit shows a lack of documentation in nursing record with telephone-advice, for example the patients problems is missing, it can lead to a poorer security of the patient. The Authors conclusion is that the district nurses who works with telephone-advice needs education in documentation, to increase and improve security of the patient in nursing and treatment.