Perioperative documentation in Finland

Abstract

In Finland, research studies about perioperative documentation are few, and there are no professional recommendations for perioperative documentation, such as AORN s Standards, Recommended Practices, and Guidelines. Exploring current documentation practices and contents used in Finland is the first step to establishing a standard for perioperative documentation. The need for this type of exploration resulted in a study that found that the aim of nursing documentation is not always clear, and current documentation practice does not necessarily reveal the decision making that directs patient care, demonstrate nursing resources needed, or provide data for evaluating and developing perioperative practice. Education, motivation, and computerization generally were mentioned as a means to develop documentation.